Credentialing Specialist

We're searching for a Centralized Credentialing Specialist, someone who works well in a fast-paced setting. In this position you will be the single point of contact and responsible for managing and completing all credentialing functions related to the Provider On-Boarding process for members of the Medical Staff and the Physician Services Organization. Responsible for ensuring providers presented to the Credentials Committee and Executive Vice President are highest quality in accordance with Bylaws and Mission, Joint Commission (JC) standards and National Council of Quality Assurance (NCQA) guidelines.

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Job Duties & Responsibilities

•    Determines applicant's eligibility for membership/participation with Medical Staff & Physician Services Organization.

•    Analyzes application and supporting documents for adherence to Joint Commission (JC), National Council for Quality Assurance (NCQA), regulatory standards and managed care delegated agreements. 

•    Recognizes, investigates, and validates discrepancies and adverse information obtained from the application, primary source verifications, or other identified sources to ensure that review and approval bodies have the information needed to make informed credentialing decisions.

•    Compiles, evaluates, and presents the practitioner-specific data collected and assembled during the verification process for review to the approving Section Chief, Department In Chief, and Credentials Committee.  

•    Creates summary of findings, prepare verification documentation, and notify Legal Counsel, Section Chief and Credentials Committee Chair within 24 hours of red flag identification. 

•    When temporary privileges are requested, analyzes application and determines if the applicant meets the minimum requirements; notifies Executive Vice President, provides provider details, and requests approval.

•    Regularly obtains, evaluates and communicates to provider and departmental leadership licensure information from primary sources. Suspends privileges and membership within 24 hours of non-compliance as documented in Bylaws, Rules & Regulations and Credentialing policies.

•    Initiates provider access and training to all applicable systems and resources.

•    When Urgent/One Time privileges are requested, responsible for immediate review, analysis of application and communication of immediate patient care needs to the Credentials Committee Chair, Service physician leadership and Executive Vice President; Submits all provider access requests and follow up with approving departments, including internal leadership.

•    Ensures compliance with Bylaws, credentialing policies, government regulations, and accreditation and regulatory standards.

•    Provides education for on-boarding providers and key stakeholders.

•    Provides reporting on provider credentialing, reappointments, and various other reports as requested.

•    Effectively communicates and appropriately represents the provider, facility, and physician group.

Skills & Requirements

•    High School Diploma or GED required

•    Bachelor's Degree Business, Finance, Healthcare Administration or Accounting preferred

•    CPMSM - Cert-Cert PROF Med Servic Mgmt preferred

•    A Provider Enrollment Specialist Certificate (PESC) from DecisionHealth preferred

•    4 year's Experience in a physician practice, physician billing, hospital or managed health care setting required

•    1-year Presentations, summary reports, and/or committee participation preferred 

•    A bachelor's degree in finance, Accounting, Business or Healthcare Administration may substitute for 2 years of experience. An associate's degree may substitute for 1 year of experience.