Credentialing Spec Ld

Children's Wisconsin • Milwaukee, WI

121d

About The Position

This position leads the credentials verification team and process of Children's Community Health Plan (CCHP) by ensuring that the processes and the staff meet credentialing policy and NCQA requirements for verifying the credentials of physicians and allied health professionals to be participating providers in the CCHP network. Takes initiative in implementing new processes or projects, is the content expert on credentialing requirements, provides training and support to Credentialing Associates, allocates processing of the applications received, and monitors work to ensure quality and timely completion of assigned work. Maintains knowledge of quality assurance and regulatory requirements directly impacting the Health Plan, such as National Committee for Quality Assurance (NCQA) and Contract for BadgerCare Plus HMO Services for Wisconsin Medicaid. In collaboration with the Manager of Clinical Quality Improvement and Credentialing, provides oversight of the Credentialing program and process including identification of and reporting any provider issues to the National Practitioner Database (NPDB), the Medical Director and the Director of Health Plan Clinical Services. Oversees training for new staff and serves as a representative at the Credentialing committee meetings.

Requirements

• High School graduate or Certificate of General Educational Development (GED) or High School Equivalency Diploma (HSED) Required.
• 2+ years credentialing experience in a health plan or other health care organization Required.
• Strong communication skills (verbal and written).
• Demonstrated strong organizational skills with ability to prioritize and meet deadlines.
• Demonstrated attention to detail and ability to demonstrate ability to work multiple projects/tasks simultaneously.
• Strong computer skills (Microsoft Office word, excel, access).

Nice To Haves

• Associate's Degree Preferred.
• CPCS-Certified Provider Credentialing Specialist - Certification Commission of National Association Medical Staff Services Preferred.

Responsibilities

• Maintains filing system, maintenance of physician files and confidentiality of information at all times.
• Acts as an organizational expert in the managed care credentialing process for CCHP.
• Provides training and support to Credentialing Associates.
• Coordinates the complex process of efficiently obtaining all critical data elements needed to effectively credential or re-credential providers.
• Assigns work for the efficient and accurate processing and verification of credentialing application information.
• Ensures work is completed in a timely basis.
• Allocates work to staff on a given shift, monitors work to ensure quality and timely completion.
• Serves as a resource to staff regarding job responsibilities.
• Developmental step to leadership, input on performance reviews, introduction to scheduling, corrective action, coaching, feedback.
• In absence of leader, is primary contact with leaders from other departments.
• Provides front line leadership to team of employees and in absence of leader.
• Serves as back-up for processing applications from physicians and allied health professionals for initial and re-credentialing to ensure completeness based on NCQA credentialing standards and the WI Contract for BadgerCare Plus HMO Services.
• Forwards all completed credentialing files to the Medical Director for review.
• Communicates with Manager of Clinical Quality Improvement and CCHP Medical Director to discuss key findings in physician file.
• Monitors WDSPS state licensures and federal sanction reports and provides updates monthly to the Manager of Clinical Quality Improvement and Credentialing.
• Obtains specific information related to physician complaints and peer review cases and forwards to the Manager of Clinical Quality Improvement and Credentialing.
• Works closely with Provider Relations and the Manager of Clinical Quality Improvement and Credentialing during the credentialing process to ensure all credentialing requirements are met, appropriate procedures are followed and that additional information is sought if necessary.
• Initiates implementation of new processes required to meet credentialing requirements or new processes for making the credentialing process more productive and efficient.
• Maintains working knowledge of NCQA and State of Wisconsin credentialing standards, rules and regulations.
• Understands the importance of and is responsible for maintaining accurate practitioner information into the CCHP credentialing database.
• Maintains a log or system to track and communicate progress of credentialing process.
• Supports the Credentialing Committee with meeting preparation, the compilation of credentialing monthly minutes and coordination of follow up items.
• Prepares all correspondence for both medical staff and allied health professionals.
• Completes reports to the National Practitioner Database (NPDB) and any other entity required by NCQA, the State of Wisconsin and/or the Federal Government.
• Performs any administrative duties required to maintain the account for the National Practitioner Database (NPDB).
• Updates/maintains the Credentialing Policies and Procedures to keep in compliance with NCQA’s Standards and updates according to CCHP’s credentialing processes.
• Works with the CCHP NCQA Project Manager to support mock audits, draft policy changes, and ensure compliance with timelines for NCQA audit.

Benefits

• Equal opportunity / affirmative action employer.
• Commitment to creating a diverse and inclusive environment for all employees.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED
• Number of Employees: 1,001-5,000 employees