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The Credentialing Coordinator is responsible for all aspects of credentialing and re-credentialing of health care professionals. This position ensures all health care professionals are appropriately credentialed, which includes the responsibility of maintaining current information on file and within the credentialing database. This position primarily works independently, but frequently coordinates with other team members, Credentialing Manager and Medical Director.
• Completion of health care professionals credentialing and re-credentialing applications.
• Data entry of new applications in the credentialing database.
• Maintain working knowledge of the National Committee on Quality Assurance (NCQA) standards, State, and Federal regulations related to credentialing.
• Perform and collect PSV (primary source verification) documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on NCQA standards, health plan requirements and company credentialing policies. • Maintain the credentialing database and ensure up-to-date information is obtained at all times.
• Responsible for monitoring and managing credentialing/re-credentialing requirements and to ensure the collection of all required renewal certifications are on file within the required time frame.
• Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
• Prepare and scan credentialing/re-credentialing files and other credentialing documentation into scanning software.
• Prepare credential committee grids and any adverse action documentation.
• Attend monthly credentials committee meetings as requested by manager.
• Answer credentialing telephone line and provide support to physicians, physician office staff, health plan contacts and company departments as necessary. • Process provider demographic changes ensuring appropriate documentation has been submitted with the changes, update credentialing database and notify health plans of changes.
• Process provider network terminations, specialty/category changes, leave of absence requests.
• Audit Disciplinary reports, OIG reports, and other reports as required and initiate the formal complaint procedure when applicable.
• Assist with annual delegated credentialing audits and National Committee on Quality Assurance (NCQA) audits.
• Participate in Medical Staff Services (MAMSS) State and Chapter meetings.
• Cross train within department to support credentialing operations (providing back-up support for telephones, credentialing files, vacation/PTO).
• Participate in various educational/training as required.
• Perform other related duties as assigned by management.
• Comply with HIPAA and Corporate Compliance program policies and other applicable corporate and departmental policies.
• Maintain privacy and confidentiality at all times
• Cross train within department to support credentialing operations
• Participate in various educational/training as required.
• Perform other related duties as assigned by management.
• Comply with HIPAA and Corporate Compliance program policies and other applicable corporate and departmental policies.
• Maintain privacy and confidentiality at all times
Qualifications
• Associates Degree preferred. High school diploma required. • Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) certification preferred • Minimum of four (4) years credentialing experience.
• CACTUS or MDStaff experience preferred.
• Experience with CAQH (Council for Affordable Quality Healthcare) database and application process.
• Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards also preferred.
• Health plan experience preferred
Skills
Must be able to operate a general computer, fax, copier, scanner and telephone.
• Must demonstrate exceptional communication skills, listening effectively and asking questions when clarification is needed.
• Ability to follow instructions and respond to Managements’ directions accurately.
• Demonstrates accuracy, organizational and problem-solving skills. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Maintain confidentiality.
• Work independently, prioritize work activities and use time efficiently.
• Must demonstrate and promote a positive team-oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must possess ability to manage change, delays, or unexpected events appropriately.
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