Job Description

Essential Duties and Responsibilities:

The Credentialing Specialist, under general supervision, coordinate initial credentialing and re-credentialing processes.  Review applications received from physicians and allied health professionals for completeness and accuracy, obtaining verification of licensure, education/training, board certification, malpractice claims history, disciplinary actions, and sanctions for presentation to the Credentials Committee.  Maintain credentialing database by updating information received during initial credentialing and re-credentialing processes.  Act as a liaison between the provider and medical staff / credentialing offices for purposes of obtaining medical staff membership and privileges. 

  • Process initial credentialing and re-credentialing applications for physicians and allied health providers.
  • Review and analyze applications and credentialing documents for initial credentialing and re-credentialing, assessing completeness of information and qualifications to established standards.
  • Identify and flag adverse information from application materials for the purpose of conducting special follow-up investigations in preparation for Credentials Committee review.
  • Prepare, issue, track and follow-up on appropriate verification letters for adequate processing of each individual application, applying established procedural guidelines.
  • Prepare completed credential files for presentation to Credentials Committee.
  • Assist Director with preparing Credentials Committee meeting dates, agendas, minutes and spreadsheets.
  • Process requests to obtain membership and privileges for providers with hospitals, surgery centers, nursing homes, and other health care facilities.
  • Respond to requests verifying provider’s affiliation with DMG.
  • Enter data from provider applications into credentialing database, interpreting or adapting data to conform to defined data field uses.
  • Perform bookkeeping activities for all primary source verification and credentialing expenses allocating to the appropriate division.
  • Enter contact and action notes into credentialing database to maintain accurate record of progress with processes.
  • Run data reports for various basic configurations of data such as provider profiles, pending provider lists and expired credentials.
  • Assist Director in compliance with the accrediting and regulatory agencies (i.e., JCAHO, NCQA) in regards to credentialing while developing and maintaining a working knowledge of the statutes and laws.
  • Assist Director in preparation for audits by health plans for delegated status.
  • Internally audit, organize and maintain provider files and information in accordance with established principles of legal documentation, following confidentiality guidelines.
  • Employ public relations skills in a wide variety of contacts with internal and external sources for purposes of soliciting information essential to credentials investigations.
  • Establish and maintain a professional working relationship with providers, their outside office staff, internal staff, and hospital staff.
  • Proficient in the use of Visual Cactus (credentialing database) to enhance the credentialing process and become proficient with its reporting functions.
  • Proficient in the use of Microsoft Word and Excel for Visual Cactus; NPI (National Practitioner Identification on-line access); IQRS (National Practitioner Data Bank on-line access); Certifacts (American Board of Medical Specialties on-line access); AMA Physician Masterfile on-line access; AOA Physician Profile on-line access; State licensing agencies on-line access and Internet Explorer for other internet access.
  • Perform related duties as assigned by supervisor.
  • Maintain compliance with all company policies and procedures. 

Requirements
Experience:

  • 3+ years in a hospital or managed care setting credentialing experience preferred
  • Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.
  • Previous experience with initial and on boarding credentialing.

Education:

  • High school diploma or equivalent
  • Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.

Knowledge/Skills/Abilities: 

  • Demonstrate and maintain knowledge of all aspects of credentialing including legislative and regulatory compliance, internal processes, policies and procedures. Keep abreast of new and changing regulations and standards
  • Understanding of the need for the credentialing process in the health care environment and the impact on quality patient care
  • Working knowledge of the National Association for Quality Assurance Standards and Guidelines for MCO accreditation
  • Working knowledge of the credentialing process
  • Familiarity with The Joint Commission Medical Staff standards and the requirements for credentialing and privileging
  • Understanding/compliance of HIPAA laws and regulations
  • Computer proficiency (MS Office – Word, Excel and Outlook)
  • Highly organized with excellent attention to detail and a demonstrated high regard for clerical accuracy
  • Excellent verbal and handwriting skills, including ability to effectively communicate with internal and external customers.
  • Ability to read, extract and interpret information comparing such to established departmental policies
  • Excellent customer services and public relations skills required
  • Must be flexible and willing to work extra hours during peak workloads and deadlines
  • Ability to work as a team player with willingness to assist other team members as needed.
  • Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service
  • Self-motivated with the ability to work independently and to carry out assignments to completion within parameters of instructions given, established time frames, prescribed routines, and standard accepted practices.
  • Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners and shredders.
  • Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards
  • Ability to type __35__wpm 

Position Type/Expected Hours of Work

  • This is a full-time position. Days and hours of work are Monday through Friday, 8:00 a.m. to 5 p.m. Occasional evening and weekend work may be required as job duties demand.

Physical Requirements:

  • Must be able to lift and carry up to 20 lbs
  • Must be able to talk, listen and speak clearly on telephone
  • Requires sitting and standing associated with a normal office environment.
  • Manual dexterity needed for using a computer keyboard.
  • Specific vision abilities include close vision, distance vision, depth perception and the ability to adjust focus.

Environmental Working Conditions:

  • Normal office environment.
  • The noise level of the work environment is usually low to moderate.
  • Occasional overtime maybe required and/or hours may be shortened as business needs dictate.