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Credentialing Specialist

3 months ago

Hillsboro, United States Virginia Garcia Memorial Health Center Full time
Job DescriptionJob DescriptionAt Virginia Garcia Memorial Health Center, we welcome diversity; we encourage, uplift, and are honored to serve people who have been historically underrepresented and underserved. Our mission is to provide high-quality, culturally appropriate healthcare to low-income residents of Washington and Yamhill Counties, with a special emphasis on seasonal and migrant farm workers and others with barriers to receiving healthcare. We strive to provide an inclusive environment that welcomes and values the diversity of the people we employ and serve.

If you are unsure whether you meet all of the required qualifications for this role but are interested and passionate about this potential position, we encourage you to apply.

Starting Rate: $22.3823/hr +DOE
Schedule: Monday-Friday 8:00am-5:00pm

Job Summary: The Credentialing Specialist performs credentialing, privileging, and re-credentialing of licensed independent practitioners and other licensed staff. This position works collaboratively with the Billing and HR departments on credentialing of providers for all insurers and Medicare/Medicaid enrollment. The Credentialing Specialist maintains confidential credentialing files and provider database and is responsible for communicating with clinical directors and clinicians regarding credentialing and privileging.

Essential Duties and Responsibilities:

  • Perform credentialing, privileging, and re-credentialing of licensed independent practitioners and other licensed staff.
  • Perform primary source and other verifications of license, registration, certification, education, training, insurance, affiliations and experience at initial appointment and reappointment in accordance with VGMHC policies and federal regulations.
  • Ensure credentialing process for insurers and Medicare/Medicaid enrollment or reassignment of benefits is performed in an accurate and timely manner.
  • Collect supporting documentation for privileging requests.
  • Perform National Practitioner Data Bank queries, check professional liability claims history, and Medicare sanctions.
  • Obtain peer and professional references and recommendations.
  • Coordinate with teaching institutions to credential residents enrolled in the VGMHC Residency Program.
  • Process and prepare credentialing applications/files for Medical Director and Board of Directors review at appointment and reappointment.
  • Maintain confidential credentialing files and provider database.
  • Maintain credentialing files, ensuring completeness, accuracy, and confidentiality.
  • Maintain provider database, including provider numbers, appointment/reappointment dates, license expiration dates, registration and/or certification, and credentialing status with insurers.
  • Track and notify providers when updated information is needed, e.g. license, registration, certification, CME, etc.
  • Collect reports/certificates of CME credits, give providers information on numbers of CME credits obtained since prior credentialing and alert providers well in advance of re-credentialing.
  • Obtain information on procedures performed and track requests for additional privileges.
  • Communicate effectively with clinical leadership, providers, Billing, HR, and Credentialing staff regarding credentialing, privileging, and scheduling.
  • Ensure all provider phone numbers, email addresses, and pager numbers are kept up to date.
  • Coordinate with hospital medical staff offices to assist providers with hospital credentialing and privileging.
  • Maintain open communication with the provider staff, medical leadership, and administration to identify and work to solve problems as they arise. Bring problems to the attention of medical leadership, Quality Assurance staff and/or Credentialing team as they arise.
  • Act as a liaison between providers and administrative staff.
  • Other duties and responsibilities.
  • Adhere to the VGMHC Code of Ethics and Quality Improvement standards.
  • Assist with development of policies and documents necessary for an effective credentialing process.
  • Assist with preparation of forms and gathering of information and materials related to QI or process improvement.
  • Assist with new provider orientation as needed.
  • Perform other duties as assigned.

HIPAA Requirements:

The Credentialing Specialist may be exposed to PHI in the course of their duties and will handle protected information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Credentialing Specialist is required to read the content of these records only to the extent needed to accomplish the assigned task (e.g. filing or disclosure).

Knowledge, Skills and Abilities:

  • Ability to comfortably interact with professional staff of VGMHC and be a pleasant and responsive contact person for outside organizations.
  • Detail-oriented, highly organized, and process focused.
  • Proficient with Microsoft office suite (Word, Excel, Outlook), and database software.
  • Exhibits a high degree of responsibility for confidential matters.
  • Ability to self-manage and effectively manage workload.
  • Demonstrated effective written communication, verbal communication and interpersonal skills.
  • Effective time management and logical decision-making skills.
  • Ability to embrace change and innovation when appropriate.

Education and Experience:

  • High School diploma or equivalent.
  • Two years’ prior experience in a healthcare setting required.
  • Previous experience in medical administration and credentialing strongly preferred.
  • Experience in a primary care setting preferred.

Behavioral Competencies:

Accountability: Role model VG’s mission, vision, and shared values

Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations

Teamwork: If someone needs help, help them

Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work

Confidentiality: Maintain strict confidentiality and respect the privacy of others

Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work

Respect: Demonstrate consideration and appreciation for co-workers and patients

Communication: Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others

Physical Requirements:

Percentage of time spent:

  • Standing: 5%
  • Walking: 5%
  • Sitting: 80%
  • Lifting/Carrying: 2%
  • Bend, Reach, Stoop – 2%
  • Use of Computer – up to 80%
  • Able to lift/carry up to 25 lbs. on occasion.

Working Environment/Physical Hazards

  • Working environment – In an office setting

Office Equipment

  • Computer – data entry and word processing
  • Telephone
  • Fax/copier/scanner

Immunization:
Staff members must meet immunization requirements as stated in VGMHC’s immunization policy and state and federal guidelines.


Job descriptions represent a general outline of the essential and major job duties, functions and qualifications required. They cannot be all-inclusive and comprehensive due to the dynamic nature of work performed to accomplish VGMHC’s Mission.

VGMHC is an Equal Opportunity Employer. No person is unlawfully excluded from consideration for employment because of race, color, religious creed, national origin, ancestry, sex, age, veteran status, marital status, or physical challenges. The policy applies not only to recruitment and hiring practices, but also includes affirmative action in placement, promotion, transfer, rate of pay and termination.