Credentialing Specialist

Chapters Health System • FL

80d

About The Position

The Credentialing Specialist is responsible for coordination and oversight of the organizations credentialing functions. Works closely with Medical Staff leaders, Administration, Human Resources, and members of the Medical Staff regarding initial and subsequent credentialing packages as required for enrollment in health plans, professional demographic tracking, collaborative practice agreements, and provider onboarding. Ensures compliance with regard to credentialing standards.

Requirements

• High School Diploma or GED required; College degree in business or health-related field preferred.
• Minimum of one (1) year experience in Medical Staff credentialing within Hospital or Physician Practice setting, or applicable Medical Office experience.
• Experience in healthcare credentialing and enrolling individual providers through PECOS, NPPES, CAQH, Managed Care Organization, commercial plans, and various clearinghouse portals like Navinet and Availity preferred.
• CPMSM and/or CPCS Certification by the National Association Medical Staff Services strongly encouraged.
• Medical Terminology expertise preferred.
• Excellent typing, organizational, and time management skills.
• Expert working knowledge of a variety of software including word processing, excel and Smart Sheet development and management.
• Well-developed communication (verbal and written including editing documents).
• Excellent interpersonal communication skills and the ability to empathize with others.
• Possesses excellent judgment and the ability to maintain professional relationships and boundaries when working with internal and external clients, colleagues and organizations.
• Ability to lead by example, adhering to the highest standards of professional work ethics and confidentiality.

Responsibilities

• Implement and maintain procedure to credential prospective new medical staff and re-credential existing medical staff for all entities within the Organization.
• Maintain current individual medical staff provider files to include all current necessary medical staff documentation and provide credentialing information in a timely manner.
• Maintain and manage professional demographics, including practice location and COIs for all Medical Staff.
• Track expiration date for the state DEA, professional license, Board Certification, and Malpractice insurance of individual providers.
• Enroll new providers and groups with government payors and coordinates, monitors, and maintain the revalidation process with government payers.
• Enroll providers in all appropriate commercial health plans and maintain revalidation process.
• Obtain, complete accurately, and timely submit enrollment applications and related documents and ensure provider collected information is current and accurate.
• Complete regular follow up with the payors to ensure applications are being processed.
• Maintain CMS Medicare, Medicaid, PECOS, NPPES, and CAQH tracking log to ensure all necessary portals logins are active and available.
• Work with individual providers to ensure each provider’s CAQH database files are updated timely according to the schedule published by CMS Medicare/ Medicaid regulations.
• Prepare, submit, and monitor status of provider files/applications for facility privileging.
• Complete and document credentialing of contracted network providers and facilities in accordance with applicable regulations and internal policies and procedures, to include uploading of evidence in any applicable contracting/credentialing software/applications.
• Ensure termination of enrollment with health plans upon resignation or termination of providers.
• As directed, provide updated demographic information with supporting documents to outside participants, contracted billing entities.
• Work closely to ensure all individual providers are credentialed and recredentialed timely.
• Responsible of collaborating and advising as appropriate to limit company legal liability and escalates non-compliance issues and concerns.
• Develops, implements and maintains procedure to credential prospective new medical staff and re-credential existing medical staff for all entities within the Organization.
• Process two-year reappointment updates for all existing medical staff and ensures credentialing processes implemented are compliant with Accreditation standards.
• Coordinates with Medical Liability Insurance Agent to secure medical liability insurance coverage for prospective medical staff.
• Maintains credentialing database by creating and implementing procedures for medical staff licenses/certifications tracking and updating including, but not limited to, medical license, DEA, UPIN, board certifications, malpractice insurance, CMEs, CEUs, contracts, and privileges.
• Maintains current medical staff files on each individual member to include all current necessary medical staff documentation and provide credentialing information in a timely manner.
• Secures necessary documentation and assists with completion of applications to obtain privileges in designated hospitals for medical staff.
• Processes applications for community hospital privileges and reappointments including all appropriate documentation and payment.
• Processes enrollments for Medicare, Medicaid and other insurance plans.
• Maintains active OIG list.

What This Job Offers

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