Credentialing Coordinator
AmeriHealth Mercy Family of Companies - Indianapolis, IN

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Position Summary:

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.

Principal Accountabilities:
  • 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.

Position Qualifications/Requirements:

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
Care environment
· 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.

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