Under the supervision of the Manager of Credentialing, the Credentialing Coordinator is responsible for initiating, processing, and completing the credentialing and re-credentialing functions for practitioners and providers. Credentialing Coordinator responsibilities include proactive identification and resolution of issues related to variance between provider information and credentialing criteria; maintenance of knowledge of NCQA and state Medicaid regulations; and adherence to productivity and accuracy standards associated with credentialing functions.
- Processes provider applications in an accurate (with 95% accuracy) timely manner within the 180-day verification time limit.
- Reviews applications for completeness of the application and supporting credentials, including current status of all time-sensitive information
- Enters data of all initial credentialing and recredentialing application into the Visual Cactus credentialing database.
- Requests and obtain all missing information and/or updated information related to the application or source documents.
- Obtains primary source verification of licensure, education and training, and specialty board certification via telephone, fax or online.
- Queries online databases for malpractice and sanction reports.
- Applies credentialing criteria to gathered information to determine provider status with respect to meeting credentialing requirements.
- Verifies, research, and respond to telephone inquiries and written inquiries, from providers and other departments, pertaining to provider participation and credentialing status in a professional and courteous manner.
- Documents time, source and content of information requested and received in the Visual Cactus system in a manner to support a complete audit trail of all activity.
- Communicates clearly and effectively when interacting with facilities, provider offices and providers to collect needed information.
- Acts autonomously to troubleshoot problems with information received in support of the credentialing process.
- Obtains provider performance reports for the credentialing and recredentialing process.
- Site visit scores (credentialing)
- Site visit and medical record review scores (recredentialing)
- Transfer notes (recredentialing)
- Member complaints (recredentialing)
- Obligation reports (recredentialing)
- Quality of care issues (recredentialing)
- Provider improvement activities (recredentialing)
- Incorporates updated information and provider profile information in the recredentialing file.
- Prepares completed credentialing and recredentialing files for final approval by the Medical Director and/or Credentialing Committee by determining the following:
- Status of the file as clean or problem for further review
- Flag all problems in the practitioner file for Medical Director Review.
- Follow-up on issues generated from Medical Director or credentialing committee reviews.
- Performs post committee data entry of credentialing status/decisions and comments.
- Prepares credentialing files and materials for regulatory and accreditation audits, including NCQA, DOH/DOI and state Medicaid agency.
- Creates scheduled and ad-hoc reports of credentialing activity.
- Prepares agenda, materials and post-meeting minutes for Credentialing Committee meetings.
- Serves as subject matter expert and quality test resource for software upgrades and maintenance.
- Adheres to strict confidentiality guidelines and Code of Conduct standards.
- Performs data entry corrections resulting from Visual Cactus system data audit reports.
- Undergoes reliability audits on credentialing and recredentialing files using the NCQA audit tool.
- Submits a monthly productivity report to the Manager of Credentialing.
- Reviews credentialing processes and policies and provide recommendations for improvement.
- Supports and advances the QM function by participating as requested in related process and activities.
- Adheres to established guidelines as defined by Company/Department policy.
- Report to work each day at assigned time;
- Maintain professional appearance as defined by Company Policy;
- Adhere to established guidelines regarding absenteeism as defined by Company Policy;
- Cooperate with manager to adjust work schedule to accommodate Department needs;
- Maintain a courteous, friendly and professional attitude towards co-workers and customers;
- Demonstrate competence and good judgment in daily planning to identify and complete priority
- responsibilities on time.
- Performs other duties as assigned by Department Manager
- Demonstrates flexibility and willingness to assist other Department personnel as necessary to meet
- shifting priorities within Department:
- Demonstrates enthusiasm, dedication and commitment to Department goals and objectives
- Contributes ideas and suggestions to improve department functions.
- Accepts other duties as a challenge and opportunity to learn.
- Pursues opportunities for personal development, knowledge and increased responsibility.
Education and Training:
· Associate or Bachelor’s degree in related field preferred
· Associates degree in related field required, Bachelor’s degree preferred
· Three (3) to Five (5) years experience with the Credentialing functions, Health Information
Management (i.e. Medical Record Keeping), or Medical Staff Coordination, preferably in a Managed
· Knowledge of Microsoft office application, Internet functions, and database application, with ability
retrieve information using selected criteria.
· Knowledge of basic Health Care, Managed Care principles, and Medical terminology preferred.
Licenses, Registrations or Certifications: Credentialing Specialist Certification Specialist preferred.
AmeriHealth Caritas - 21 months ago