Ins Credentialing Coordinator

Position Summary: Ensures that all medical staff practitioner and allied health professional credentialing regulations are adhered to and that all medical professionals are properly enrolled with insurance carriers to provide and bill for services. Coordinates, monitors, and maintains the credentialing and re-credentialing processes for all medical staff practitioners and allied health professionals, and ensures verification of licenses and are documented to meet insurance regulations and are enrolled with participating insurance agencies.

Verifies the professional licensing, training, and certifications of professional medical staff and allied health professionals with the requirement that all employed healthcare professionals and services meet all federal and state medical standards, The Joint Commission (TJC), Center for Medicare Services (CMS), as well as NCQA (National Committee for Quality Assurance) requirements, and other regulatory agencies. Responsible for the accuracy and integrity of the credentialing database system and related applications.

Critical Tasks:

• Process insurance credentialing applications to participating insurance plans for claim, billing and revenue purposes; processes re-credentialing applications as required by various insurance plan carriers and completes the re-enrollment process for providers terminated by insurance carriers.
• Verifies medical professional staff credentials in a fully accurate manner.
• Ensures that the licenses and credentials of medical professionals are properly documented to meet insurance company preferences and state/federal insurance regulations.
• Maintains working knowledge of various payer credentialing process, required procedures/forms, and workflow process
• Performs research through multiple sources while using multiple research interfaces and data sources.
• Coordinates work activities with other credentialing team members.
• Coordinates and correlates payer contracts.
• Participates in cyclical audits and reviews.
• Maintains detailed knowledge of differing insurance carriers and service networks.
• Maintains detailed knowledge of medical licenses and resulting authorities for credentialed medical staff and allied health professionals; CAQH (Council for Affordable Quality Healthcare), NPI (National Provider Identifier), as well as any new professional licensed services implemented by GRHC.
• Analyzes and interprets inferences from many research and data sources (fee schedules, procedure protocols, etc.)
• Utilizes database management systems for the purposes of querying, reporting and adapting to using software programs.

• Keep up-to-date provider enrollment process and records, and track provider participation.
• Update the system and the credentialing database to reflect approvals, denials, and/or terminations.
• Obtains and utilizes information such as government agency protocols, provider information, and enrollment procedures.
• Investigates and corrects claim/billing issues resulting from credentialing errors and failures.
• Processes insurance applications quickly and accurately in response to any insurance, regulatory or provider changes.
• Maintains and continually updates personal knowledge of all credentialing standards, bylaws, regulations and regulations, policies, and Greater Arizona Central Credentialing Program (CVO) requirements.
• Prepares CAQH and NPI registration applications for newly affiliated and existing to providers, or other provider required entities maintaining database ensuring up-to-date tracking of process.
• Maintains close communication with all medical professionals to ensure that all records are current and consistent.
• Immediately terminates provider credential registrations for terminated providers, upon notice of such terminations.
• Performs other special projects and duties as assigned.

Required Qualifications:

• High school diploma required
• College degree preferred.
• Three years of experience in a medical credentialing role in a healthcare environment.
• Certified Provider Credentialing Specialist (CPCS) by the National Association of Medical Staff Services preferred or actively pursuing certification.
• Exceptional organizational, time management and planning skills in deadline-intense environment.
• Demonstrated ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures.
• Demonstrated ability to regularly change priorities to accomplish all tasks despite frequent interruptions.
• Demonstrated ability to clearly communicate, both orally and in writing, while performing all essential functions.

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