Credentialing and Privileging Specialist

About the role

Bancroft is a leading service-provider for children and adults with autism, other intellectual or developmental disabilities or those in need of neurological rehabilitation. We provide a full continuum of highly effective services — for people of all ages and every level of abilities — based on best practices and scientifically proven techniques. Our services include special education, vocational training, supported employment, structured day programs, group home and apartment programs both on-campus and in the community, short-term behavioral stabilization services for children, and in-home and outpatient rehabilitation services.

Responsibilities

• Leads, coordinates, monitors and maintains the privileging, credentialing and re-credentialing processes.
• Facilitates all aspects of Bancroft credentialing; including initial appointment, reappointment, clinical privilege for Medical Staff, Allied Health Professionals and all other providers outlined in the Medical Staff bylaws, policies, or related contracts.
• Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while maintaining a working knowledge of the statues and laws relating to credentialing.
• Responsible for the accuracy and integrity of the credentialing database system and related applications.
• Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
• Independently processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege policy descriptions.
• Exercises independent review of related data to determine if the applicant may proceed in the process or if further information is needed.
• Independently conducts thorough background investigation, research and primary source verification of all components of the application file.
• Identifies any issues that require additional investigation and evaluation, validates discrepancies and independently assures follow up with appropriate departments and staff.
• Prepares credential files for completion and presentation to Board of Directors, ensuring file completion within time periods specified.
• Monitors the initial, reappointment and expiration process for all medical staff, Allied Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (Federal, State, CMS, Joint Commission, etc.).
• Leads organizational and individual provider credentialing to ensure participation, including but not limited to Medicare, Medicaid and managed care insurance providers.
• Independently establishes CAQH accounts for onboarding clinical providers and complete all CAQH applications.
• Independently leads managed care credentialing audits; conducts internal file audits.
• Prepares and submits enrollment applications to managed care insurance providers.
• Responds to any questions and completes any related follow up.
• Prompts responses to inquiries from other healthcare organizations, internal and external customers.
• Provides education to Bancroft staff members regarding credentialing requirements.
• Maintains a detailed log and/or database of all pending and completed work.
• Researches and resolves any issues relating to provider/clinician NPI numbers.
• Manages the deactivation of provider numbers, effective dates, and prepares notification of deactivation status.
• Provides weekly updates regarding status of any outstanding practitioner applications.
• Indicates any cause of delay in process.
• Maintains and verifies provider demographic information every 90 to 120 days for active clinical staff through various means and applicable payer portals, email notifications, phone calls, and facsimiles.

Qualifications

• High school diploma required.
• At least 3 years’ experience, with 2 years directly related to hospital, physician group, managed care, outpatient practice or human service field credentialing.
• Preference: National Association Medical Staff Services (NAMSS) certification as a Certified Medical Services Manager (CPMSM), or Certified Provider Credentials Specialist (CPCS), or ability to be certified within one year.
• Demonstrated ability to effectively communicate both verbally and in written form required.
• Ability to think and work independently.
• Meet deadlines and assure that assigned projects are completed in a timely and efficient manner.
• Effective interpersonal skills.
• Operative knowledge of MS Office Word and Excel spreadsheets preferred.
• Valid driver’s license required in incumbent’s legal name and current address with no provisional restrictions.
• Minimum 18 years of age required.