Credentialing Auditor
AmeriHealth Mercy Family of Companies - Philadelphia, PA

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Position Summary: Under the supervision of the Director of Credentialing, the Credentialing Auditor is responsible for maintaining the quality and reliability of the collection and verification of practitioner applicant’s professional qualifications. Additionally, the Auditor is responsible for data analysis, action plan development and assisting in the establishment and achievement of business objectives.

Principal Accountabilities:

  • Audits 100% of credentialing and recredentialing files, submitted by credentialing coordinators and senior credentialing coordinators to ensure compliance with relevant accreditation and regulatory standards and internal policies and procedures. The coordinator/auditor may also audit data entered into the Credentialing database.
  • Monitors the Credentialing Clerical Support Staff files.
  • Returns audited files showing errors to the relevant credentialing coordinator who originally prepared the file, for the purposes of data correction, education and coaching for all credentialing coordinators.
  • Provides monthly audit reports including trend identification, and opportunities for improvement
  • in order to provide individual and department level performance improvement plans.

  • Conducts quarterly analysis using audit data and presents results to Credentialing associates and management.
  • Assists in the development of Credentialing policies and standing operating procedures.
  • Assists in the establishment and achievement of business objectives based upon Company’s overall strategic plan and operating goals.
  • Demonstrates leadership skills and sets an example of personal performance which encourages excellence in integrity.
  • Communicates clearly and concisely using strong decision making, negotiation and conflict resolution skills.
  • Adheres to established guidelines as defined by Company/Department policies.
  • Maintains current knowledge of computers, systems, and applications that impact operations of Credentialing.
  • Keeps current with NCQA, DPW, IBC Credentialing regulations and guidelines.
  • Maintains current knowledge of Credentialing and Auditing industry trends.
  • Perform 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.

  • Supports and carries out the Mercy Mission and Values.

  • Key Competencies/Success Factors:

    · Proficiency with Microsoft Office applications (Excel, Word, Access).

    · Proficiency in use of related applications/internal systems to collect information necessary to

    complete principal accountabilities (e.g., Healthcare System, MACESS/IMAX, Facets).

    · Effective verbal and written communication skills.

    · Ability to plan own schedule, set priorities and work independently in accomplishing work assignments

    on time.
    • Attention to detail.
    • Strong analytical skills.
    • Strong negotiation skills.

    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.

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