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March 9, 2016
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April 2, 2016

Credentialing Specialist

SUMMARY

Under the direction of the Management Team the Credentialing Coordinator is responsible for coordinating the credentialing process which includes gathering all credentialing materials, maintaining up to date records and documentation, out reach to health plans for follow up and problem resolution, and ensuring ongoing compliance as required by regulatory agencies. Monitors current licensing, malpractice coverage and DEA information and communicates to Director/Manager/Supervisor and/or appropriate staff any discrepancies or variances as necessary. Key functions also include maintaining up-to-date computer programs to record and/or update information as necessary.
Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. These functions include but are not limited to the following:

 

  • Coordinates the process of gathering all credentialing materials as mandated by NCQA and Health Plans, assuring files are complete with all the necessary documents before forwarding them to the contracted health plans.
  • Maintains an up-to-date physician database, including medical licenses, drug enforcement administration certificates, and professional liability insurance, and renewal period expiration dates.
  • Monitors and conducts appropriate follow-up regarding supportive credentialing documentation including current licensure, malpractice status and history, board certification, medical staff dues, and related functions according to established time frames.
  • Acts as a liaison between the physician and payers as it relates to credentialing. Takes action when warranted on credentialing issues. Communication of findings back to the management team and providers.
  • Maintains current and organized medical staff credentialing files, including applications and reapplication forms, record of licensure, DEA, education and other pertinent information.
  • Assists with inspections by regulatory authorities and/or health plans. Ensures the security and confidentiality of credentialing files.
  • Follows up with each contracted health plan both in writing and/or verbally to assure acceptance can be accomplished as quickly as possible to avoid any loss of revenue, or delays in credentialing.
  • Resolves contracting issues as it pertains to credentialing, (i.e., incorrect or lack of provider or site information issues with health plan)
  • Resolves a variety of various issues with payers, patients, plans and providers and responds to both written and verbal inquiries for miscellaneous information (e.g., providers’ current documentation, W-9 information, status of credentialing process with specific providers, etc.)
  • Assist with credentialing file audits of participating health plans
  • Frequent health plan roster reviews and updates.
  • Prepares for and actively participates in credentialing committee meetings and activities

 

Required Education and Experience

  • Working knowledge and understanding of the medical insurance industry and health plans
  • Proficient computer navigation skills, with basic/advanced Microsoft Office/Outlook, Excel and intra/internet experience
  • Medical Terminology
  • Ability to comprehend departmental NCQA, Payer and policies and procedures related to credentialing.
  • Skills in gathering, analyzing and evaluating data in order to provide input to decisions, problems solve difficulties and anticipate need for changes.
  • A moderate level of analytical ability is required. Work is performed in accordance with standard procedures but does require basic technical knowledge or in-depth, experience-based knowledge in order to analyze and interpret information.
  • A significant level of communication and interpersonal skills is required in order to explain policies or otherwise communicate with others in situations requiring sensitivity and tact.
  • Work is performed in accordance with instructions and procedures but incumbents organize the work, set priorities and request occasional exceptions when necessary.
  • Work requires the ability to use a keyboard to enter, retrieve or transform words or data, and closely examine reports. Accuracy and attention to detail are essential.
  • Work is generally performed in an office in which entail working knowledge of, business machines (photocopier, fax), above-average computer skills (word processing, databases, spreadsheets, internet, and email).

Education and/or Certification/Licensure

High School Diploma and greater than 3 years equivalent experience in a managed care environment with primary focus on credentialing or accreditation activities for physicians/facilities is required.

  • An Associate or Bachelors Degree is preferred.
  • Certification as a Certified Provider Credentialing Specialist (CPCS) and/or Certified Medical Staff Coordinator (CMSC) preferred.

Experience

  • Three years experience working in a managed care environment with primary focus on credentialing or accreditation activities.
  • Experience working with physicians and clinical staff in a medical or clinical setting
  • Knowledge of credentialing and/or accreditation requirements is required
  • Experience in telephonic, production oriented and metric driven work environment

Medical Terminology