Credentialing Specialist

2 weeks ago

Arlington, United States George Washington Medical Faculty Associates Full time

The GW Medical Faculty Associates (MFA) was incorporated in July 2000 as a not-for-profit, physician-led practice group. The organization functioned as an independent organization in support of The George Washington University School of Medicine and Sciences as a multi-specialty physician practice group. The GW MFA has grown to become the largest independent academic physician practice in the Washington, DC metro region with more than 500 physicians and nearly 200 APP providers. In 2018, the MFA bylaws were revised to allow The George Washington University to serve as the sole corporate member while the MFA retained independent 501c3 status. The purpose of the change was to ensure alignment between the MFA and The George Washington University.

MFA physicians provide comprehensive patient care, offering one practice for the whole person with 52 medical and surgical specialties. As members of the GW School of Medicine and Health Sciences faculty, MFA providers are teachers and mentors for medical students, residents, fellows, and researchers preserving the rich tradition of academics, research, and healing. In addition to maintaining a closely integrated alliance with The George Washington University and The George Washington University Hospital (GWUH) which is separately owned and operated by Universal Health Services (UHS), the GW MFA has active referring relationships with 12 area hospitals.

**The GW MFA’s leading healthcare presence in the DC metro region is complemented by a network of community-based practices in DC, Maryland, and Virginia. Given its geographic location in central NW Washington, DC, and proximity to more than 175 resident embassies, the MFA continues to evolve its international clinical outreach.**:
**Position Summary**:
**Perform day-to-day credentialing and re-credentialing activities for providers within the Credentialing Department. Performs payor enrollment and maintenance with payors on a regular basis. Maintain customer-focused relationships with MFA departmental contacts to ensure a smooth and efficient credentialing process.**:
**Essential Duties and Responsibilities**:
**To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned.**:
**Credentialing & Privileging** - conduct and participate in credentialing and privileging activities (40%)**:

- Determine the practitioner’s eligibility for membership/participation to ensure compliance with accreditation and regulatory standards.
- Compile, evaluate, and present practitioner files for committee review to ensure compliance with accreditation and regulatory standards.
- Ensure the provider numbers for the governmental payors are loaded in the billing system to ensure the timely release of claims to the payors.
- Update the medical/professional licenses that are about to expire with DC Medicaid, Maryland Medicaid, and Virginia Medicaid.
- Work with the billing department to make sure rejections for credentialing-related reasons are addressed in a timely fashion and the charges are resubmitted for payment.

**Primary Source Verification** - Conduct primary source verification activities (20%)**:

- Obtain and evaluate information from acceptable primary sources to ensure compliance with accreditation and regulatory standards.
- Verify and track expired documents utilizing acceptable verification sources to ensure compliance with accreditation and regulatory standards.
- Perform primary source verifications of licensure, board certification, DEA/CDS certification, education/training, Medicare/Medicaid sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB queries.

**Compliance** - Comply with accreditation and regulatory standards (15%)**:

- Participate in the development, implementation, and ongoing assessment of bylaws, rules/regulations, and policies and procedures to ensure continuous compliance with accreditation and regulatory standards.
- Prepare documentation and participate in on-site audits from delegated credentialing entities to ensure compliance with accreditation and regulatory standards.
- Perform ongoing monitoring and evaluate practitioner sanctions, complaints, and adverse actions to ensure compliance with accreditation and regulatory standards.

**Operations** - Support departmental/organizational operations (25%)**:

- Meet or exceed individual productivity metrics, quality, and timeliness standards as defined by department guidelines and current workload.
- Maintain credentialing database (MD-Staff); track collection of NPI, Medicare, Medicaid, DEA, CSC, and state licenses; update practitioner records as appropriate.
- Conduct research and resolve issues related to outstanding provider numbers from all governmental payors.
- Inform practitioners and stakeholders of credentialing decisions; send letters, reports, and systems updates in a timely manner.
- Coordinate committee meeting logistics, documenta

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