Credentialing Coordinator

•Knows, understands, incorporates and demonstrates the mission, vision and values in leadership behaviors, practices and decisions.•Maintains a working knowledge of applicable Federal, State and local laws and regulations, Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
•Maintains a thorough understanding/knowledge of the NCQA and URAC credentialing and recredentialing standards and how they relate to the credentialing/recredentialing processes.
•Coordinates the verification process for initial and recredentialing applicants through continuous monitoring and deciding the appropriate credentials required and perform the verification of pertinent credentialing information from various sources.
•Coordinates and set-up contracts and ensure correct contracts is.
•Oversees the maintenance of all credentialing hard copy and electronic files and related documents and determine system parameters for producing statistical reports.
•Maintains credentialing/recredentialing information in the credentialing database and generates documents, reports and correspondences for management.
•Ensures timely, accurate and complete verification of credentials according to policy and procedures. Ascertains and determines which provider profiles and reports are to be submitted to management.
•Identifies inconsistencies in credentialing information and initiates extensive investigation into background, education and experience through the use of on line systems, written correspondences, telephone inquires, reference guides and reports.•Exercises good judgment in handling the release of confidential and sensitive information. Daily release and audit ascertain and dissimulate information to appropriate authorities.
•Reviews application for missing information and pursues the missing information or further documentation from providers.
•Conducts civil and criminal background checks.
•Maintains provider information into the credentialing database and updates the database as appropriate. Executes fact-finding and performs as a liaison between client and external organizations.
•Responds to telephone inquiries regarding status of application, request to join network, and clarification of participating criteria.
•Coordinates credentialing committee process, including preparation of applications, reports, and agenda packets for review.•Compiles and reviews credentialing information for presentation to the credentialing manager, medical director, and credentialing /quality improvement committees.•Produces reports, profiles and provider information forms through requesting the information from the credentialing database
•Interfaces and provides credentialing updates to Physician Organizations, Provider Relations and Contracting staff. Works collaboratively to resolve provider issues.
•Assists the credentialing manager and support the credentialing committee.
•Coordinates and maintains credentialing and quality committee meeting schedules and minutes.•Conducts credentialing and recredentialing audits of provider credentials and determines if provider meets clients participating and contracting criteria.•Prepares provider records within 45 days of assignment to be reviewed by medical director or credentialing committee.
•Participates in Quality Improvement activities and other duties as needed and assigned by management.
•Accurately set-ups provider reimbursement for services in the database.
REQUIREMENTS
•Must possess a comprehensive knowledge of Health Care Credentialing, privileging, data management as normally obtained through an Associates Degree in Health Care or Business Administration or a related field and 3-5 years of credentialing experience or an equivalent combination of education and related work experience. Bachelor’s degree preferred.
•Certified Professional Credentialing Specialist (CPCS) Certification Preferred.
•Excellent organization, interpersonal, oral and written communication skills.
•Ability to work independently with demonstrated problem solving, organization skills and attention to detail.
•Ability to release and maintain confidential information and work under pressure.
•Working knowledge of NCQA, URAC and State of Michigan laws for credentialing.
•Ability to operate PC based applications, Word, Access, Excel.
•Ability to meet weekly performance expectations.
•Working knowledge of database management and Internet navigation to obtain physician and provider information.•Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values.
•Must be comfortable operating in a collaborative environment.
•Must be able to adapt to frequently changing work priorities, and be able to set own work priorities and balance the requirements of working with member organizations.
•Must be able to travel in state to various group sites (approximately 10%)
•Must possess the ability to comply with policies and procedures.