Credentialing Specialist

3 weeks ago


Neptune City, New Jersey, United States Hackensack Meridian Health Full time

About the Role

Hackensack Meridian Health is seeking a skilled Delegated Credentialing Coordinator to join our team. In this role, you will be responsible for coordinating and performing all credentialing functions, including pre-delegation and annual due diligence audits, to ensure compliance with National Committee for Quality Assurance (NCQA), contractual agreements, and State and Federal requirements.

Key Responsibilities

  • Complete delegated and traditional credentialing files accurately
  • Demonstrate a solid understanding of credentialing and NCQA guidelines
  • Verify the accuracy of all submitted credentialing information and create or audit accurate Primary Source Verification (PSV) files for delegated credentialing
  • Perform all activities related to physician credentialing, re-credentialing, and delegation, including identifying discrepancies in information and conducting follow-up
  • Present applications to the Credentialing Committee and assist customers with credentialing inquiries
  • Respond to health plan provider inquiries and capture primary source documentation
  • Ensure data is backed up and compliance with all applicable laws, regulations, procedures, and policies
  • Assist in maintaining credentialing policies and procedures
  • Participate in delegation audits and supply information as needed
  • Perform tasks related to external audits from contracted health plans/employer groups and pre-delegation review with potential health plans
  • Monitor providers due for recredentialing and confirm they are recredentialed timely
  • Coordinate with delegated partners to ensure adherence to all regulations, contractual agreements, NCQA, HIPAA, and URAC guidelines
  • Support the use of process and performance improvement data to support best practice processes and implement change as needed
  • Collaborate with CVO leaders in support of an ongoing performance improvement and reporting process that is accurate, timely, and action-driven
  • Provide and support ongoing communication with CVO leaders, especially in regards to risk/issues identified during the credentialing/recredentialing process for delegated credentialing
  • Contribute and support technology integration and migration with other system information systems as needed
  • Provide support to Manager, Credentialing and Coordinators to help ensure continuous compliance with state and federal laws, organization policies, regulatory agencies, and accrediting body standards
  • Participate in department teams processes to confirm compliance on an ongoing basis
  • Assure confidentiality is maintained at all times in all aspects of delegated credentialing process
  • Consult with Medical Services Professionals (MSPs in MSOs, CVOs, MCOs, etc.)
  • Other duties and/or projects as assigned

Requirements

  • High School diploma, general equivalency diploma (GED), and/or GED equivalent programs
  • 2+ years in industry healthcare setting
  • 1+ years in Enrollment/Delegated Credentialing
  • Takes accountability, uses initiative, possesses critical thinking skills, uses good judgment, seeks guidance as needed
  • Strong interpersonal skills, teamwork, and communicates effectively
  • Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity
  • Overall working knowledge of software programs with a drive to incorporate technology in all operational functions
  • Strong organizational skills
  • Detail-driven
  • Excellent communication skills
  • Gets results
  • Drives service excellence


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