Credentialing Specialist

This position conducts the day-to-day activities associated with credentialing or re-credentialing licensed practitioners (M.D., D.O., P.A.-C., N.P., D.D.S., etc.), ancillary providers (acute care facilities, durable medical equipment organizations, laboratories, etc.) and other service providers for the purpose of network participation. These responsibilities include the processing of provider applications and re-applications (initial mailing, review, and loading into the database tracking system, etc.) and ensuring high quality standards of review and evaluation are maintained during such process. He/she will assist with identifying new providers added to contracted groups and collecting the appropriate documentation to ensure timely credentialing can be initiated for those providers. The Credentialing Specialist will work closely with the Network Services Contracting department to ensure the database tracking system is updated and maintained appropriately.

The Credentialing Specialist may assist with Delegation Oversite Audits, internal audits, and in the development and maintenance of departmental policies and procedures. He/she will be looked to as a resource to provide feedback in effort to reduce errors and improve processes and performance within the department. This position will have direct communications with the Credentialing Verification Organization (CVO), shall such a relationship exist, and/or conduct all primary source verification activities. The Credentialing Specialist will assist in preparing documentation for Credentialing Committees and will participate in the data entering and communication of the results of each committee held.

This position must help meet company quality, compliance and accreditation standards regarding credentialing and re-credentialing and ensure our file completion reviews meet and/or exceed regulatory, state and federal mandated standards. The information they access is sensitive and extremely confidential. This information must be handled discretely and member safety is paramount.

This position will be responsible for the coordination and implementations of the provider credentialing and re-credentialing process including initiating the paperwork, obtaining documentation, assisting the provider licensure process, if necessary, and obtaining approval, signatures and ensuring timely contract effective dates as preferred provider with the insurance plan. This position is responsible for coordinating and ensuring policies and procedures are followed for all provider credentialing appeals. This position works closely with various internal and external departments to ensure rapid and accurate credentialing and re-credentialing for committee approval and maximum access to providers is available to members.

This position is responsible for the continuous monitoring of the Hometown Health provider network against all federal and state exclusion and preclusion lists. This position is responsible for reporting providers to the National Practitioner Data Base as applicable.

This position is the primary point of contact to ensure accurate and timely communication of the status of a provider within the credentialing process. This position is responsible for coordinating and communicating the results of each Credentialing Committee and updating the provider database.

This position must maintain a direct knowledge of industry changes, URAC Standards, Medicare Requirements and State Regulations that could affect the credentialing and re-credentialing process and/or impair reimbursement. Must maintain knowledge of Hometown Health's products and networks.

This position is responsible for ensuring department policies, procedures, and practices are aligned with URAC Standards, Medicare Requirements, and State Regulations.

This position maintains documentation in an electronic fashion of all minutes for future reference for accreditation and audits, i.e. URAC, CMS, etc.

This position assures that follow-up action from meetings is taken and applied as indicated and documented in the Medical Affairs Committee meeting minutes, to ensure Hometown Health remains in compliance with all accrediting bodies, CMS, and state regulations.

This position maintains a monthly and annual Calendar of all Medical Affairs Committee Meetings.

This position is responsible for the timely and electronic processing of all practitioner initial and reappointment applications.

This position maintains accuracy of the electronic database system used at Hometown Health for the tracking of all past, present and future applicants and is responsible for the accuracy of the reporting of provider re-credentialing timeframes.

This position must use diplomacy and discretion, with the respect to confidentiality. The measure of success for this position will be provider satisfaction, client satisfaction and member satisfaction, when possible.

Routine work is performed independently with the employee responsible for decisions made regarding those assigned duties. The employee must demonstrate professional competence, exercise diplomacy, judgment and tact in a service-oriented manner and as a self-manager at all times.

Maintaining organization and efficiency to handle multiple responsibilities and quickly shifting priorities in an environment of constant interruptions.

Clear and concisely communicate detailed information in both verbal and written form and have the ability to handle complex inquiries. Extensive knowledge of managed care, URAC, HMO's, PPO's and other provider networks. Problem solving skills to effectively handle unusual situations with employer groups, physicians, their office staff, and the third parties while maintaining the best interest of Renown Health and Hometown Health.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

AA or BA/BS preferred. High School Diploma and a command of the English language, including reading, writing and speaking English.

Experience:

Two years of provider credentialing experience required. In lieu of credentialing experience, at least 5 years progressive administrative or office management experience. Experience working with legal counsel or executive management preferred. Knowledge or URAC, State, and Medicare requirements is a plus.

License(s):

None

Certification(s):

Prefer at least CPCS certification with the National Association of Medical Staff Services. If not certified at time of hire and based on prior experience, employee will become CPCS certified within 3-4 years.

Computer / Typing:

Must have excellent writing skills and strong organizational skills. Must have excellent interpersonal and communication skills, as this position interacts with physicians, legal counsel, and other Senior Leaders across the organization. Must be experienced in word processing and the use of menu driven computer applications.