Credentialing Specialist

DETROIT WAYNE Integrated HEALTH Network • Detroit, MI

1d • Hybrid

About The Position

Under the general supervision of the Director of Managed Care Operations and the direct supervision of the Credentialing Administrator, the Credentialing and Impaneling Specialist performs tasks to ensure that all DWIHN practitioners and provider organizations are credentialed prior to performing services in the DWIHN system. The Credentialing Specialist also ensures healthcare professionals and facilities meet all established federal and state standards, as well as NCQA (National Committee for Quality Assurance) standards.

Requirements

• Knowledge of DWIHN policies, procedures and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations and procedures.
• Knowledge of Federal policies, rules, regulations and procedures as it relates to DWIHN.
• Knowledge of Credentialing principles and practices.
• Knowledge of the Medversant software system.
• Knowledge of MHWIN.
• Knowledge of compliance standards.
• Knowledge of NCQA requirements and the accreditation process.
• Assessment skills.
• Evaluation skills.
• Organizational skills.
• Interpersonal skills.
• Communication skills.
• Computer skills (Word, Excel, Access, Power Point, Outlook, Teams).
• Teamwork Skills.
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
• Judgement/Reasoning ability.
• A High School Diploma, a GED or its equivalent.
• Four (4) years of full-time paid professional experience performing administrative duties and responsibilities.
• One (1) year of full-time paid professional experience performing credentialing and impaneling duties and responsibilities.
• A valid State of Michigan Driver’s License with a safe and acceptable driving record.

Nice To Haves

• Certified Provider Credentialing Specialist (CPCS) certification

Responsibilities

• Completes review of provider credentialing and re-credentialing applications checking for completeness and accuracy.
• Prepares reports for the Credentialing Committee on provider file status.
• Completes National Practitioner Database Check, Systems for Award Management database check, MDHHS Sanctioned Providers List, and OIG checks as appropriate.
• Maintains, tracks and monitors the expiration dates of SAM Registration, accreditation, and license expiration and notifies providers as needed.
• Manages the Credentialing process using the Medversant system.
• Serves as the primary contact for the Managed Care Operations unit for Medversant and other Credentialing provider inquiries.
• Provides instruction and training to the DWIHN Provider Network on the Credentialing process.
• Responds to all Provider Requests for new applications and questions regarding the Credentialing process.
• Provide status updates for providers and practitioners.
• Assists in updating policies and procedures for the Credentialing process.
• Completes Readiness Reviews of Providers upon request.
• Maintains database of approved services to determine the capacity of the Provider Network.
• Prepares and sends approval letters to providers.
• Collects and processes verification and accreditation information.
• Updates and maintains accurate databases for facilities and practitioners.
• Attends Credentialing Committee, subcommittee and other meetings.
• Maintains confidentiality of all Provider/ practitioner information.
• Performs related duties as assigned.

Benefits

• Proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED