Credentialing Coordinator
AmeriHealth Mercy Family of Companies - Philadelphia, PA

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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 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
    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