Credentialing Administrator I

Job Location: 135 Corporate Woods, Ste 380, Rochester, New York, United States of America, 14623

Full-time, Regular position with a scheduled 40-hour work week during day shifts.

Compensation Range: $27.16 - $38.03 per hour. Individual salaries will be determined based on factors including market data, education, experience, qualifications, expertise, and internal equity considerations.

Responsibilities

• Coordinates departmental activities to ensure quality in conducting, maintaining, and communicating practitioner credentialing, privileging, and primary source verifications.
• Serves as a resource to and collaborates with management and others to advance the quality of practitioners and patient safety of the facility.
• Coordinates Activities for Ensuring Compliance with Accreditation Standards and Regulatory Requirements:
  • Develops and/or updates applicable governing documents (bylaws, credentialing policies and procedures, privileging policies, etc.) to ensure compliance with all regulatory agencies governing healthcare.
  • Assists management with the NCQA Accreditation application and survey process, including completing the online application, coordinating payments and scheduling, and participating in the survey process.
  • Completes monthly ongoing monitoring for all active providers and quarterly quality improvement metrics for NCQA survey submission.
  • Represents MSS and the CVO for regulatory audits/surveys by the JC, NCQA, DOH, CMS, Delegated Commercial Payers, and other regulatory agencies as needed.
  • Serves as the MSS Representative on the Joint Commission Steering Committee.
  • Provides education to staff pertaining to medical staff bylaws, policies, and procedures.
  • Collaborates with national and state leaders and associations, attends educational seminars/conferences to remain current with best practices, evolving standards, and industry technology.
• Clinical Privileging and Delineation of Privileges:
  • Assists with the clinical privileging program and the development and maintenance of specialty-specific, criteria-based delineations of privileges.
  • Collaborates with Department Chiefs, Division Heads, clinical leaders, Quality Management, and other subject matter experts to ensure privilege criteria remain current, evidence-based, and compliant with standards.
  • Assists in the development and review of privilege criteria for new procedures, technologies, and services.
  • Provides administrative oversight and compliance monitoring of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) documentation.
• Data Management and Process Improvement Functions:
  • Develops and implements tools and policies to support knowledge management, record-keeping, and internal/external communication.
  • Maintains data security and ensures access is limited to appropriate staff and clients.
  • Develops, coordinates, and monitors quality initiative activities, including tracking staff performance and completion rates.
  • Reviews performance measures and goals with staff regularly and develops improvement plans as needed.
  • Conducts ongoing review and assessment of departmental functions to identify areas for improvement and implement changes.
  • Maintains accurate reporting on active and historical medical and allied health professional staff.
  • Assists with URMFG’s Delegated Credentialing/Commercial Payer Enrollment Contracts with over 25 contracted commercial payers.
  • Reviews new and existing commercial payers delegated credentialing contracts for appropriateness.
• Department, Committees, and Board Approval Process:
  • Prepares applicant credentials files for presentation to the CPRC process, including document collection and file preparation.
  • Electronically routes credentials files to department chiefs/chairs for review and recommendation.
  • Coordinates the weekly expedited credentials committee and board approval process for Strong Memorial Hospital and Highland Hospital.
  • Coordinates emergency privilege requests for all UR affiliates.
  • Monitors and updates staff status of appointments and privileges.
  • Prepares board letters and special mailings upon committee and board approval and communicates outcomes to practitioners and departments.
• Performance Management and Recruitment:
  • Recruits and supervises qualified staff to accomplish departmental operations and functions.
  • Assesses performance and processes to identify areas for improvement and resource utilization.
  • Develops performance improvement plans for staff not meeting goals.
  • Collaborates with management on overall supervision of Medical Staff Services Department staff, including team building and retention strategies.
• Liaison and Leadership Support:
  • Assists with URMFG’s Delegated Credentialing/Commercial Payer Enrollment Contracts.
  • Prepares practitioners' credentials files for presentation to affiliate and non-affiliate CVO clients and coordinates electronic routing.
  • Coordinates the proxy credentialing process associated with telehealth activities.
  • Engages in ongoing collaboration with Credentialing Managers and other Coordinators.
  • Represents the Medical Staff Office and CVO for regulatory audits/surveys.
  • Responds to inquiries from other healthcare organizations and interfaces with internal/external customers on credentialing and privileging issues.
  • Serves as a resource for staff regarding medical staff bylaws, policies, and procedures.
  • Represents the Medical Staff Services Department for various initiatives and committee meetings.
  • Serves as the primary backup to all credentialing staff and as a Team Peer Interviewer as needed.

Requirements

• Associate's degree in business or healthcare-related field and 3 years of experience in Medical Staff credentialing and/or payer enrollment functions or equivalent combination of education and experience.
• Fluent English language skills (oral and written).
• Proficiency in MS Office (Word, Excel, PowerPoint), email, and internet.
• Knowledge of and experience with Joint Commission, CMS, and NCQA Regulations related to medical staff services and Commercial Payers Credentialing preferred.
• Exceptional interpersonal and communication skills.
• Ability to develop and maintain relationships with key stakeholders across the organization.
• Knowledge of and experience with database applications preferred.
• Experience with criteria-based clinical privileging process preferred.
• Demonstrated strong familiarity with clinical environments preferred.

Qualifications

• Certified Medical Professional Services Management (CPMSM) upon hire preferred.
• Certified Provider Credentialing Specialist (CPCS) upon hire preferred.