Credentialing Coord

Position Summary:

Initiate, coordinate, monitor and maintain the credentialing and re-credentialing of all practitioners and allied health staff employed and/or contracted with Clinica Sierra Vista. Will also assist to perform duties regarding various managed-care activities.

Essential Functions:

1. Completion of health care professionals credentialing and re-credentialing applications including the privileging and re-privileging for all Practitioners and allied health staff employed/or contracted with Clinica Sierra Vista. In addition, responsible for the completion of the credentialing and re-credentialing of Other Licensed and Certified Practitioners.
2. Initiates and conducts primary source verification of practitioner’s background, education/training and malpractice history through the use of online systems, written correspondence, telephone inquiries and other acceptable credentialing methods.

1. Identifies and evaluates potential red flags and works in collaboration with the credentialing manager to determine next steps.
2. Performs ongoing monthly and quarterly compliance reporting. Analysis of report data and state board sanction information in compliance with regulatory on-going monitoring requirements.
3. Is responsible for preparation of materials and files for presentation and review by credentialing committee.
4. Perform data management and reporting from credentials database.
5. Collaborates with inter-departmental peers, including Quality Management and Operations to identify and implement best practices and to ensure an integral, timely, and consistent product.
6. Works with Human Resources/Operations department/Recruitment to ensure timely credentialing of new health care professionals prior to employment.
7. Customer Focus/Communication Skills – Provides assistance to practitioner issues and/or triages appropriately, via verbal/written communication in response to both internal and external customers. Maintains a high level of service satisfaction.
8. Functional Skills – Ensures compliance with Joint Commission, Health Resources Services Administration (HRSA), National Committee for Quality Assurance (NCQA) standards and other regulatory agencies. Assists in development of policies and procedures to support the credentialing process.
9. Technical Skills – Responsible for the accuracy and integrity of the credentialing database. Able to run database queries and reports to support efficiencies and prioritization of work flow.
10. Problem Solving Skills – Identifies and responds pro-actively to issues and concerns assuring complete solutions in a timely manner.
11. Organizational Skills – Ability to juggle multiple priorities and perform expedited credentialing upon request.
12. Ability to work cooperatively in a team environment to support and advance the mission, vision and goals of Clinica Sierra Vista.
13. Is able to work independently.

Other Responsibilities:

1. Forwards completed Credentialing files to Managed Care plans for enrollment and follows up on effective dates with plans. Communicates with the billing department on enrollment completion.
2. Works closely with managed care plans for recredentialing and to ensure that providers are listed in the marketing directories for member choice.
3. Performs other work-related duties as assigned.

Qualifications:

1. Any combination equivalent to: An associate’s degree AND one year of credentialing experience in a managed care setting or experience in the medical field with a thorough understanding of credentialing and privileging. Background of strong administrative skills will also be considered.
2. Certified Provider Credentialing Special (CPCS) desired.
3. Working knowledge of accreditation standards, including Joint Commission, NCQA, HRSA and CMS preferred.
4. Knowledge of MD Staff (ASM) preferred.
5. Proven ability to function independently with minimal direct supervision required.
6. Strong organizational and communication skills required.
7. Excellent oral and written communication, interpersonal and computer skills required.
8. Proficient in Microsoft Office Suite (Outlook, Word, Excel).
9. Comfortable extracting and formatting data for ad hoc report requests.
10. Attention to detail a must.
11. Confidentiality required.

Physical Requirements:

Bending/Twisting 5%

Walking 5 %

Sitting 70%

Push/Pulling 2%

Reaching Overhead 2 %

Driving 1 %