Credentialing Coordinator

Mercyhealth•Janesville, WI

3d•Onsite

About The Position

The Credentialing Coordinator is responsible for maintaining high-quality, timely, and accurate credentialing processes for medical providers, behavioral health providers, and allied healthcare professionals. This role manages the entire credentialing lifecycle, including initial credentialing, re-credentialing, add-on applications, and ongoing maintenance. The coordinator ensures compliance with system policies, NCQA Standards, and state/federal regulations, acting as the point person for the No Surprises Act (NSA). Key duties include tracking and verifying credentials, managing missing documentation, identifying potential red flags, advising the Medical Director on questionable information, and managing sanctions and complaints. The role also involves maintaining credentialing databases, building reports, managing the provider/facility directory, and supporting audits and re-certification processes. Additionally, the coordinator participates in workgroups, maintains knowledge of NCQA standards, develops Standard Operating Procedures, and assists with provider onboarding and manual reviews. Collaboration with contracting and provider management departments is essential for data accuracy. The position requires strong attention to detail, excellent communication skills, and proficiency in Microsoft Office and credentialing software.

Requirements

Associate's degree and 1 year of healthcare credentialing experience preferred (healthcare facility, managed care setting, CVO, or medical staff office), OR a minimum of 2 years of experience in credentialing (preferred), OR a minimum of 3 years of experience in a business support area required.
Must be able to follow written/oral instructions.
Demonstrated proficiency in Microsoft Office (Word, Excel, Access) and other applications, as required.
Demonstrates knowledge of credentialing software; Maintains confidentiality of privileged information.
Knowledge of accepted practices related to primary source verification.

Nice To Haves

Experience with credentialing accreditation by NCQA.
Demonstrated working knowledge of healthcare and credentialing industry, including medicolegal issues and laws, regulatory agencies, and other national standards preferred.
Understanding of professional telephone etiquette.
Able to work with minimal supervision and under pressure.
Able to work well in individual and group environment.
Proactively prioritizes needs.
Shows attention to detail.
Communicates clearly and concisely.
Must have excellent interpersonal and written communication skills, including spelling, grammar and basic mathematical calculations.
Establishes and maintains long-term customer relationships by building trust and respect.
Articulates knowledge and understanding or organizational policies, procedures, systems.

Responsibilities

Maintains high quality, timely and accurate credentialing processes of medical providers, behavioral health providers, and allied healthcare professionals based upon system policies and procedures.
Manages the entire credentialing process by entering, logging, scanning information into the system for initial credentialing, re-credentialing, add-on applications and maintenance.
Completes and ensures compliance, confidentiality and delivery of required information to all credentialed providers in a timely manner.
Manages all aspects of credentialing and recredentialing in accordance with MercyCare policies and procedures, NCQA Standards, State and Federal regulatory guidelines.
Serves as the point person for the No Surprises Act (NSA) to ensure regulatory compliance.
Ensures that all credentials are current and complete pursuant to expiration date of medical licensure, board certification, professional liability insurance coverage, DEA and other pertinent information per MercyCare policy/procedure.
Manages collection of all information received and follows up on missing items/documentation/incomplete forms.
Identifies and evaluates potential red flags and works in collaboration with practitioner(s) to document the issue and practitioner response.
Advises MercyCare Medical Director of questionable information received and any issues identified during processes.
Manages sanctions and complaints on a monthly basis and reports any findings to the Medical Director, Director of Network Development, the Medical Staff Office, and the credentialing committee.
Makes appropriate and accurate entries into applicable systems to activate the practitioner and ensure practitioner inclusion in rosters, directories, and reports.
Manages all credentials files to ensure that all correspondence is accurately filed.
Meets and maintains productivity standards as outlined by the department.
Manages meetings for the credentialing committee, including sending notices, drafting agendas, assembling meeting materials, drafting minutes, and follow-up correspondence.
Maintains information in credentialing database and other systems, and builds queries and reports in credentialing software.
Manages all aspects of the MercyCare provider/facility directory, ensuring compliance with regulatory and NCQA standards.
Manages project implementation and upgrades of credentialing software.
Participates in workgroups and maintains current knowledge of NCQA standards.
Develops and maintains all Standard Operating Procedures for credentialing.
Attends webinars or continued education meetings.
Participates in HEDIS, as applicable to credentialing.
Manages delegated audits on an as-needed basis.
Assists in the Medicaid re-certification process on an annual basis.
Assists providers in signing up for access to the MercyCare directory.
Participates in the annual review of the MercyCare Provider Manual.
Works closely with the MercyCare Contracting department and provider management department to ensure all data is accurate.
Manages surveys to providers to ensure most accurate cultural responsiveness is on file.
Manages weekly, monthly, quarterly and annual reports and distributes information to appropriate departments in a timely manner.