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Centralized Credentialing Spec Government Clinics
3 months ago
The Centralized Credentialing Specialist Government Clinics processes practitioner applications for initial appointments and/or reappointments by following The Joint Commission (TJC), National Committee for Quality Assurance (NCQA) and other State Regulatory requirements. Thoroughly reviews and evaluates applications. Identifies extraordinary information, discrepancies, time gap and obtains additional explanation and information as required. Plays a proactive role in process improvement.
Job Responsibilities
- Processes practitioner applications for initial appointment and/or reappointments.
- Manages, supports and maintains credentials files on all medical staff members and advanced practice providers. Consults and works with other hospital departments to coordinate process.
- Assures compliance with regulatory requirements and accrediting body standards, Bylaws and policies. Consistently reviews regulatory requirements, accrediting body standard, Bylaws and policies to maintain current knowledge.
- Initiates and processes application with thorough review and evaluation.
- Plays a proactive role in improving processes within the department for maximum efficiency by participating/leading process improvement activities.
- Communicates status of application to practitioners and all interested parties.
- Appropriately identifies and escalates extraordinary information, time gaps and potential discrepancies and adverse information, and independently investigates and validates information on applications, primary source verifications or other sources.
- Conducts follow-up and research regarding additional required information. Documents appropriately.
- Manages, supports and maintains the Network Insurance Credentialing process for appropriate employed practitioners.
- Completes audit updates on Network Insurance files.
- Obtains additional information for all Network Insurance applications with pending and closed lawsuits.
- Works to ensure applications are completed within the required timeframe to meet the appropriate Credentialing Committee Deadlines.
- Reviews Privilege request forms for accuracy and provides criteria as appropriate. Notifies practitioner that privilege will be withdrawn if criteria not received by deadline.
- Maintains credentialing database continuously and consistently to ensure that accurate and current information is available to all stakeholders.
- May perform other duties as assigned.
Additional Requirements
Certification - Top Secret Security Clearance (ISSA/TS/SCI) required within 12 months. If team member does not hold Top Secret Security Clearance (ISSA/TS/SCI) at the time of hire, the Team Member must obtain it within one year of the hire date
Experience - 1 year of experience in a healthcare setting or customer service; or, BA degree and no experience.
Education - High School diploma or equivalent
