Credentialing Specialist

Job Summary

Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all medical providers and clinical staff who provide patient care. Ensures providers are credentialed, appointed, and privileged with health plans, and patient care facilities.

Maintaining Credentials

• Maintains credentialing files in adherence to HRSA guidelines as it pertains to the credentialing and privileging clinical staff guidelines.
• Maintains communications with insurance vendors to ensure providers are up to date.
• Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed.
• Reviews and ensures documents submitted are current and correct.
• Processes applications for appointment and reappointment of privileges within time-sensitive deadlines.
• Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
• Tracks license, DEA and professional liability expirations for appointed providers.
• Compiles and ensures that accurate licenses, DEA and professional liability documents are secured and maintained in all providers’ files.
• Compiles and ensures current CPR and First Aid certificates are maintained in providers’ files.
• Works in tandem with the Director of Clinical Education and Support regarding providers re-training in CPR and First Aid.
• Provides copies of updated certificates to the Director of Clinical Education and Support.
• Maintains corporate provider contract files.
• Maintains knowledge of current health plan and agency requirements for credentialing providers.
• Sets up and maintains provider information in online credentialing databases (CCNV) and system.
• Tracks license and certification expirations for all providers to ensure timely renewals.
• Routinely communicates with agents on the status of filings with insurance companies.
• Ensures practice addresses are current with health plans, agencies and other entities.
• Audits health plan directories for current and accurate provider information.
• Assists with the new hire process for LIP’s and OLIP’s.
• Provides assistance with provider chart review.
• Maintain providers’ credentialing files to ensure a healthcare facility is operating within state and federal regulations.

  Nonessential Functions

  • Assist in resolving audit issues assigned by the Chief Medical Officer and Chief Human Resources Officer.
  • Performs other administrative duties as assigned by the Chief Executive Officer.
  • Supervisory Responsibility: None.
  • Managerial Responsibilities: None.

  Qualifications

  • Associates or Bachelor’s Degree in Business Administration, Healthcare or equivalent certification of competency.
  • Three (3) to five (5) years of work experience in medical credentialing.
  • At least two (2) years of experience working in the healthcare industry or similar regulatory environment.
  • Experience working with local, state and federal agencies in regards to procuring licensing for healthcare providers including background checks.

  Preferred Qualifications

  • Certified Provider Credentialing Specialist (CPC S ).

  Physical and Mental Demands

  • Ability to remain in a stationary position 50% of the time.
  • Ability to cope with stress.
  • Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.
  • The person in this position frequently communicates with patients and/or employees.
  • Must be able to summarize and exchange accurate information.
  • Performs a variety of duties, often changing from one task to another.
  • Performs with frequent interruption or distractions.
  • Adjust priorities quickly as circumstances dictate.
  • Ability to interact appropriately with colleagues for different purposes in different contexts.
  • Expresses or exchanges information to convey detailed spoken instructions accurately, or quickly.
  • Ability to judge distances and spatial relationships to see objects where and as they actually are.
  • Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.

  Compliance

  • This position requires compliance with Greater Baden Medical Services (Health Center’s) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures.
  • Such compliance will be an element considered as part of the Director of Risk Management’s regular performance evaluation.

  Language Skills

  • Ability to read and interpret written or verbal documents and instructions.
  • Ability to speak effectively to patients, employees and/or stakeholders of the organization.