Responsible for obtaining and maintaining critical credentialing data necessary for initial reviews and the monitoring of practitioners and facilities to determine participatory status, thereby supporting the selection of contracting of practitioners who maintain the clinical skills necessary to deliver high quality of healthcare and service excellence to PacificSource members. Follow credentialing procedures to ensure timely, accurate credentialing of practitioners affiliated with PacificSource. Maintain current credentialing information and assist in communicating with practitioners on credentialing issues and practice information.
1. Review, research, and verify practitioner files and computer database records to obtain information and compile data for reports.
2. Assist in credentialing activities related to credentialing and recredentialing operations. Organize project work, maintain inter-departmental contacts on credentialing issues, and maintain credentialing status report.
3. Maintain collaborative relationships and act as a liaison between PacificSource and IPAs/physicians.
4. Conduct primary source verification on applicants, which may include but is not limited to: making requests, investigations, verifications, tracking and follow-up of responses from all required sources as required by credentialing policies and procedures.
5. Review monthly reports to assure all practitioners complete recredentaling in accordance with the assigned target date and that no practitioners are left off the recredentialing schedule. Perform verification of current professional license, DEA certificate (if appropriate), professional liability, and board certification.
6. Act as a liason to IPA groups to ensure that demographic information is entered in the system correctly.
7. Assist in preparing reports on practitioners that may have potentially adverse actions with PacificSource for the Practitioner Review committee.
8. Act as liaison to practitioners and their staff for credentialing issues.
9. Assist Provider Support Specialists to assure provider database is accurate and up-to-date in order for claims payment accuracy.
10. Maintain familiarity with contract language of National Practitioner Data Bank (NPDB), Healthcare Integrity and Protection Data Bank, State Medical Boards, the National Committee of Quality Assurance (NCQA), and other regulatory bodies.
11. Maintain strict confidentiality of all practitioners’ records, data, and occurrences.
12. Review monthly minutes received from delegated IPA groups for accuracy.
13. Load provider information into computer systems after credentialing process completed.
14. Perform other duties as assigned.
Relationships: Work closely with the Credentialing team to ensure access to credentialing status information. May serve as a primary contact to physicians, non-physician practitioners, IPA groups, and clinic coordinators. Facilitate exchange of information between internal departments and providers.
Work Experience: Minimum of two years health insurance experience, credentialing experience preferred.
Language skills: Ability to tactfully interact with medical practitioners and staffs and to handle a variety of situations. Excellent organizational and communications skills required.
Mathematical Skills: Basic math skills required, including percentages, ratios, graphing and spreadsheet skills.
Reasoning Ability: Requires ability to define and prioritize problems and manage workload without direct supervision. Ability to prioritize multiple tasks and meet deadlines.
Education, Certificates, Licenses, Registration: High School Diploma or equivalent required, Associate Degree preferred. CPCS credentialing certification preferred.
Other Skills and Abilities: Knowledge of NCQA credentialing standards. Knowledge of requirements and functions of the Credentialing Committee and Board of Directors and how each contributes to the credentialing functions. Knowledge of credentialing issues. Maintains regular contact with the Provider Network Department to update current practitioner information. Computer skills, including word processing, spreadsheet, and database applications. Medical terminology knowledge.
Work inside in a general office setting with ergonomically configured equipment. Some travel is required for training, external meetings and credentialing audits. Work hours may include early mornings, evenings, and out of town travel, occasionally over night.
Mental / Physical Requirements
Requires sitting, standing, walking, and stooping / bending according to work tasks.
Light lifting and carrying of files and department notebooks. Must be able to read text and numbers and communicate clearly and distinctly using a voice telephone and in person. Handles files, computer keyboard, writing instruments, and other appropriate office equipment.
This job description indicates the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job. Other duties or responsibilities may be assigned as required by the Medical Director, Vice President of Operations, or PacificSource staffing needs.
PacificSource is an equal opportunity and affirmative action employer.
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