Credentialing Specialist

ASM Research•Forest Park, GA

39d

About The Position

Processes credentialing and re-credentialing applications for the client. Reviews applications and prepares verification letters. Contacts various departments, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications. Provides support to the client in the collection and query of credentials of members of the client. Conducts Primary Source Verification (PSV) of credentials such as licenses, certifications, registrations, professional school education, postgraduate, residency, or specialty training, board certifications, work history, and current references. Conducts queries through the National Practitioner Data Bank (NPDB), the Defense Practitioner Data Bank (DPDB), the Department of Health and Human Services (DHHS) and TRICARE sanction data banks. Collects professional/peer references and completed clinical privileges, demographics, military and civilian practice history (including adverse privileging actions and malpractice history), health status, documentation of contingency and continuing education training, national provider identification number, and for non-personal services contract providers malpractice insurance information. Accurately loads appropriate data in the DoD Centralized Credentials Quality Assurance System (CCQAS). Keeps records and documentation of the applications and verifications maintained. Establishes and maintains updated CCQAS records. Researches and solves credentialing/re-credentialing problems; escalates more complex issues as appropriate. Tracks status of credentials for healthcare practitioners and provides required documents to clients to make accession, credentialing and privileging (C&P) decisions. Maintains relationships with Military Treatment Facilities and supported customers. Ensures providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities. Reviews records for regulatory compliance and quality assurance at a healthcare facility, insurance group, or similar organization, ensuring relevant regulations are met.

Requirements

HS diploma or GED
2-5 years of experience performing physician credentialing at a medical group, hospital or health plan
Strong customer focus, interpersonal, collaboration, written/verbal communication, prioritization and computer skills
Strong attention to detail and good organizational capability
Able to handle multiple simultaneous tasks and complete work projects in designed time frames
Ability to handle confidential information on a daily basis in a professional manner
Ability to consistently maintain quality and production expectations
Possess proof-reading skills sufficient for auditing documents
Demonstrate familiarity with credentialing policies, guidelines, and regulations for the DoD credentialing process

Nice To Haves

Bachelor's Degree in healthcare or business field preferred
Certified Provider Credentialing Specialist (CPCS) preferred
Knowledge of Department of Defense credentialing guidelines preferred
Experience using Centralized Credentials Quality Assurance System (CCQAS) and Defense Medical Human Resources System - internet (DMHRSi) a plus

Responsibilities

Processes credentialing and re-credentialing applications
Reviews applications and prepares verification letters
Conducts Primary Source Verification (PSV) of credentials
Conducts queries through various data banks
Collects professional/peer references and other information
Accurately loads data in CCQAS
Maintains updated CCQAS records
Researches and solves credentialing/re-credentialing problems
Tracks status of credentials for healthcare practitioners
Maintains relationships with Military Treatment Facilities and supported customers
Ensures providers are credentialed, appointed, and privileged
Reviews records for regulatory compliance and quality assurance