Credentialing Coordinator
AmeriHealth Mercy Family of Companies - Philadelphia, PA

This job posting is no longer available on AmeriHealth Caritas. Find similar jobs: Credentialing Coordinator jobs

Position Summary: Under the supervision of the Manager of Credentialing, the Credentialing Coordinator is responsible for initiating, processing, and completing the credentialing and recredentialing functions for KMHP/AMHP practitioners and providers. The Credentialing Coordinator responsibilities include maintaining knowledge of NCQA and DPW regulations, maintaining productivity and accuracy standards associated with the credentialing functions.

Principal Accountabilities:

  • Process provider applications in an accurate (with 90% accuracy) timely manner within the 180-day verification time limit.
  • Review applications for completeness of the application and supporting credentials, including current status of all time-sensitive information
  • Document the date of receipt of applications and the initials of the coordinator assigned to process the credentialing/recredentialing on provider applications and supporting documents.
  • Enter data of all initial credentialing and recredentialing application into the Visual Cactus credentialing database.
  • Request and obtain all missing information and/or updated information related to the application or source documents.
  • Establish a credentialing file for all new applicants.
  • Incorporate updated information and provider profile information in the recredentialing file.
  • Perform primary source verification of all supporting provider credentials through telephone, fax, and online systems within the 180-day verification time limit.
  • Obtain primary source verification of licensure, education and training, and specialty board certification via telephone, fax or online.
  • Query online databases for malpractice and sanction reports.
  • Communicate clearly and effectively when requesting verification of hospital privileges.
  • Obtain 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)
  • Submit completed credentialing and recredentialing files to the Manager of Credentialing for review 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.
  • Perform post committee data entry of credentialing status/decisions and comments.
  • Provide accurate and timely response to inquiries regarding provider status as it relates to the credentialing and recredentialing process.
  • Perform data entry corrections resulting from Visual Cactus system data audit reports.
  • Undergo reliability audits on credentialing and recredentialing files using the NCQA audit tool.
  • Submit a monthly productivity report to the Manager of Credentialing.
  • Support and advances the QM function by participating as requested in related process and activities.
  • Adhere 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.
  • Perform other duties as assigned by Department Manager
  • Demonstrate flexibility and willingness to assist other Department personnel as necessary to meet
    shifting priorities within Department:
    · Demonstrate enthusiasm, dedication and commitment to Department goals and objectives
    · Contribute ideas and suggestions to improve department functions.
    · Accept other duties as a challenge and opportunity to learn.
    · Pursue opportunities for personal development, knowledge and increased responsibility.
    Position Qualifications/Requirements:

    Education and Training:
    ·
    Associates degree in related field required, Bachelor’s degree preferred
    Experience:
    ·
    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
    ·
    Registered Health Information Administrator (RHIA), Registered Health Information Technician
    (RHIT), LPN, RN registration licensure is preferred

    AmeriHealth Caritas - 17 months ago - save job - block
    Recommended Jobs
    Provider Database Coordinator
    Health Partners, Inc. - Philadelphia, PA
    Health Partners, Inc. - 9 days ago

    Social Services Coordinator - Reed
    Devereux - West Chester, PA
    Devereux - 5 days ago

    Credentialing Coordinator
    American Medical Response - Horsham, PA
    American Medical Response - 17 days ago
    About this company
    9 reviews