Job description

About the Role:
The Credentialing Specialist, under general supervision, coordinate initial credentialing and re-credentialing processes. Review applications received from physicians and allied health professionals for completeness and accuracy, obtaining verification of licensure, education/training, board certification, malpractice claims history, disciplinary actions, and sanctions for presentation to the Credentials Committee. Maintain credentialing database by updating information received during initial credentialing and re-credentialing processes. Act as a liaison between the provider and medical staff / credentialing offices for purposes of obtaining medical staff membership and privileges.
What You Will Do

• Process initial credentialing and re-credentialing applications for physicians and allied health providers.
• Review and analyze applications and credentialing documents for initial credentialing and re-credentialing, assessing completeness of information and qualifications to established standards.
• Identify and flag adverse information from application materials for the purpose of conducting special follow-up investigations in preparation for Credentials Committee review.
• Prepare, issue, track and follow-up on appropriate verification letters for adequate processing of each individual application, applying established procedural guidelines.
• Prepare completed credential files for presentation to Credentials Committee.
• Assist Director with preparing Credentials Committee meeting dates, agendas, minutes and spreadsheets.
• Process requests to obtain membership and privileges for providers with hospitals, surgery centers, nursing homes, and other health care facilities.
• Respond to requests verifying provider’s affiliation with DMG.
• Enter data from provider applications into credentialing database, interpreting or adapting data to conform to defined data field uses.
• Perform bookkeeping activities for all primary source verification and credentialing expenses allocating to the appropriate division.
• Enter contact and action notes into credentialing database to maintain accurate record of progress with processes.
• Run data reports for various basic configurations of data such as provider profiles, pending provider lists and expired credentials.
• Assist Director in compliance with the accrediting and regulatory agencies (i.e., JCAHO, NCQA) in regards to credentialing while developing and maintaining a working knowledge of the statutes and laws.
• Assist Director in preparation for audits by health plans for delegated status.
• Internally audit, organize and maintain provider files and information in accordance with established principles of legal documentation, following confidentiality guidelines.
• Employ public relations skills in a wide variety of contacts with internal and external sources for purposes of soliciting information essential to credentials investigations.
• Establish and maintain a professional working relationship with providers, their outside office staff, internal staff, and hospital staff.
• Proficient in the use of Visual Cactus (credentialing database) to enhance the credentialing process and become proficient with its reporting functions.
• Proficient in the use of Microsoft Word and Excel for Visual Cactus; NPI (National Practitioner Identification on-line access); IQRS (National Practitioner Data Bank on-line access); Certifacts (American Board of Medical Specialties on-line access); AMA Physician Masterfile on-line access; AOA Physician Profile on-line access; State licensing agencies on-line access and Internet Explorer for other internet access.
• Maintain compliance with all company policies and procedures.
• Other duties as assigned.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be interpreted an exhaustive list of all responsibilities, and duties required of employees assigned to this job.

What You Will Bring to the Role:

• Demonstrate and maintain knowledge of all aspects of credentialing including legislative and regulatory compliance, internal processes, policies and procedures. Keep abreast of new and changing regulations and standards.
• Understanding of the need for the credentialing process in the health care environment and the impact on quality patient care.
• Working knowledge of the National Association for Quality Assurance Standards and Guidelines for MCO accreditation.
• Working knowledge of the credentialing process.
• Familiarity with The Joint Commission Medical Staff standards and the requirements for credentialing and privileging.
• Understanding/compliance of HIPAA laws and regulations.
• Computer proficiency (MS Office – Word, Excel and Outlook).
• Highly organized with excellent attention to detail and a demonstrated high regard for clerical accuracy.
• Excellent verbal and handwriting skills, including ability to effectively communicate with internal and external customers.
• Ability to read, extract and interpret information comparing such to established departmental policies.
• Excellent customer services and public relations skills required.
• Must be flexible and willing to work extra hours during peak workloads and deadlines.
• Ability to work as a team player with willingness to assist other team members as needed.
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.
• Self-motivated with the ability to work independently and to carry out assignments to completion within parameters of instructions given, established time frames, prescribed routines, and standard accepted practices.
• Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners and shredders.
• Ability to type __35__wpm.
• Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or federal, state and local standards.
• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.

Education or Equivalency

• 3+ years in a hospital or managed care setting credentialing experience.

Experience Requirements:

• High school diploma or equivalent
• Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.

Managerial Responsibilities:

• None

FTE Status/Scheduled Hours of Work:

• This is a full-time position, Monday through Friday.
• Occasional evening and weekend work may be required and/or hours may be shortened as job duties demand.

Environmental Working Conditions

• Normal office environment.
• The noise level of the work environment is usually low to moderate.

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