Medical Services Professional
About the Role:
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.
What You Will Do
- 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.
- Maintain compliance with all company policies and procedures.
- Other duties as assigned.
What You Will Bring to the Role:
- 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 type __35__wpm.
- 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 federal, state and local standards.
- Ability to maintain regular, punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.
Education or Equivalency
- 3+ years in a hospital or managed care setting credentialing experience preferred.
- 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.
- This is a full-time position, Monday through Friday.
- Occasional evening and weekend work may be required and/or hours may be shortened as job duties demand.
Environmental Working Conditions
- Normal office environment.
- The noise level of the work environment is usually low to moderate.
- Pay Type Hourly