Credentialing Specialist Managed Care

About the Role

Assists with managed care delegated credentialing audits and conducts internal file audits. Utilizes the credentialing database to optimize efficiency, performs query, report, and document generation, and submits and retrieves National Practitioner Database reports in accordance with the Health Care Quality Improvement Act. Monitors the initial, reappointment, and expirables process for all AHS-employed physicians, allied health professional staff, other health professional staff, delegated and community CIN providers affiliated with AHS. Ensures compliance with regulatory bodies as well as medical staff bylaws, rules and regulations, policies and procedures, and delegated contracts. Achieves productivity standards as determined by management. Other duties as assigned.

Coordinates and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility. Conducts thorough background investigation, research, and primary source verification of all components of the application file, ensuring provider files are current and noted in detail in the system of record. Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow-up. Prepares credentials file for completion and presentation to the Adventist Health Systems (AHS) Delegated Credentialing Committee (DCC) or other affiliated credentialing committees within AHS, including Clinically Integrated Network (CIN) committees, ensuring file completion within specified time periods. Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions. Responds to inquiries from other healthcare organizations and interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.

Responsibilities

• Assist with managed care delegated credentialing audits and conduct internal file audits.
• Utilize the credentialing database to optimize efficiency, perform queries, generate reports, and manage documents.
• Submit and retrieve National Practitioner Database reports in compliance with the Health Care Quality Improvement Act.
• Monitor initial, reappointment, and expirables processes for all AHS-affiliated providers.
• Ensure compliance with regulatory bodies, medical staff bylaws, policies, procedures, and delegated contracts.
• Coordinate and monitor the review and analysis of practitioner applications and accompanying documents.
• Conduct thorough background investigations, research, and primary source verification of application files.
• Identify and validate discrepancies, ensuring appropriate follow-up and detailed documentation.
• Prepare credentials files for presentation to credentialing committees, ensuring timely completion.
• Process requests for privileges in compliance with clinical privilege descriptions.
• Respond to inquiries from healthcare organizations and interface with internal and external customers on credentialing and privileging issues.
• Achieve productivity standards as determined by management.
• Perform other duties as assigned.

Requirements

• High School diploma or equivalent (Required).
• Associate degree (Preferred).
• Field of study in Healthcare Administration, Business, or a related field.
• 1+ years of administrative support in a healthcare setting (Required).

Skills

• Attentive to detail and accuracy; strong organizational skills (Required).
• Ability to communicate effectively, both orally and in writing (Required).
• Program planning and implementation skills (Required).
• Knowledge of related accreditation and certification requirements (Required).
• Knowledge of medical credentialing and privileging procedures and standards (Required).
• Ability to analyze, interpret, and draw inferences from research findings, and prepare reports (Required).
• Working knowledge of clinical and/or hospital operations and procedures (Required).
• Informational research skills (Required).
• Ability to use independent judgment to manage and impart confidential information (Required).
• Database management skills including querying, reporting, and document generation (Required).
• Ability to make administrative/procedural decisions and judgments (Required).
• Proficiency in Microsoft Office (Excel, Word, Outlook) and web-based applications (Required).
• Excellent organizational, planning, and time management skills (Required).
• High-level interpersonal skills; ability to work collaboratively with multi-disciplinary and diverse teams (Required).
• Ability to work independently, prioritize projects, and handle multiple projects and deadlines (Required).
• Excellent problem-solving skills and ability to cope with interruptions (Required).
• Knowledge of the Joint Commission standards and NCQA guidelines (Required).
• Ability to work in a matrix-management environment to achieve organizational goals (Required).
• Proficient in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint) (Preferred).
• Experience with MSOW/Apogee (Preferred).
• Knowledge of medical terminology (Preferred).
• Understanding of credentialing principles and regulatory standards (Preferred).
• Typing speed of 35 wpm (Preferred).

Licenses and Certifications

• Certified Professional Medical Staff Management (CPMSM) (Preferred).
• Certified Provider Credentialing Specialist (CPCS) (Preferred).

Benefits

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance.
• Paid Time Off from Day One.
• 403-B Retirement Plan.
• 4 Weeks 100% Paid Parental Leave.
• Career Development.
• Whole Person Well-being Resources.
• Mental Health Resources and Support.
• Pet Benefits.

Pay

Pay Range: $19.76 - $36.75 per hour.

Schedule

• Full time.
• Fully Remote, 8 AM - 5 PM EST.

Location

900 Hope Way, Altamonte Springs, Florida, 32714.

Physical Requirements

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law. View physical requirements here.