Credentialing Coordinator

Completes collection and process application for initial appointment reappointment and additional privileges for all credentialed practitioners.

Obtains primary source verification (verifying all elements of application directly with the source-such as medical school residency program previous hospitals licensing board and any other required source)

Maintain credentialing database.

Conducts ongoing monitoring and verification of license malpractice insurance DEA certificate and board certification for all applicable practitioners.

Conducts ongoing monitoring of sanctions or disciplinary actions such as license and Medicare sanctions.

Maintains active and archived credentialing files.

Performs delegated credentialing for health plans.

Assists in preparation and participate in the credentialing verification portion of accreditation and regulatory surveys.

Assists in the development of policies and procedures.

Develops and maintains effective working relationship with other personnel including physicians support staff billing staff insurers and department administrative personnel to expedite information exchange and resolution of common issues. Receives and answers all questions relative to third-party credentialing within scope of responsibility.

Adhere to production goals and directives.

Assists in auditing delegated credentialing functions in accordance with policies and procedures.

Audits files for completed information upon submission requests missing data from providers.

Coordinates with client health plan to ensure practitioner /hospital credentialing and enrollment lag time is at minimum levels; serve as primary liaison with client health plan for any practitioner /hospital database issues.

Participates on special projects as needed to evaluate health plan operational requirements and reimbursement.

Researches practitioner/organization issues such as payment denials due to plan participation status practitioner specialty and service locations and notifies appropriate parties.

Responsible for National Provider Identifier (NPI) number generation/tracking and revisions.

Creates and or updates existing Counsel for Affordable Quality Healthcare (CAQH) profiles. Updates should automatically be completed ensuring continuous participation with established third party payers. Reminds staff of when licensing renewals are due.

Documents Tracking/Dissemination. Forwards renewed credentials to all your affiliations to minimize repeated request for credentialing related documents. Responsible for monitoring status and immediately reporting to Manager those who do not meet the standard established by the Joint Commission.

Assists in the accurate and timely completion of Electronic Data Interchange (EDI) enrollments for electronic submission with various payors and clearinghouses including status follow up.

Creates a common understanding of the initial credentialing and recredentialing processes so those involved in credentialing activities have a better sense of what it is all about why it is important and what they can expect from health plans and hospitals. Maintains strong knowledge of managed care systems and contract related activities including legal regulatory and operation requirements. Remain current with National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS) standards to assist organization with ongoing contractual and regulatory compliance.

Stays abreast of latest credentialing developments trends and techniques.

Performs other duties as assigned.

Associates Degree in Health Services or related field preferred or equivalent combination of education and experience.

EXPERIENCE:

Minimum of three year 's relevant experience working in a Hospital physician office or multi-entity credentialing environment.

Successful experience demonstrating the use of interpersonal skills necessary to communicate and gather information from all levels of personnel and the ability to handle highly confidential data in a secure and trustworthy manner.

Knowledge of credentialing principles for Hospitals/provider networks/payers.

Intermediate computer skills credentialing software and information systems knowledge; ability to generate management and production reports documents and correspondence independently.

Current knowledge of Joint Commission requirements state regulations and credentialing processes.

Continuing education in federal and regulatory education related to credentialing as required.

Current knowledge of NCQA and Medicare credentialing standards and other regulatory requirements.

Normal working environment with little to not exposure to any adverse environmental conditions.