Credentialing Coordinator

Position Description

The Credentialing Coordinator, reporting to the Credentialing Director will be responsible for assisting in monitoring and maintaining the credentialing and re-credentialing process. Support the Credentialing Director in the facilitation of all aspects of URAM/HU Health System credentialing, including initial appointment reappointment, expirable process, as well as clinical privileging for Medical Staff, Allied Health Professionals, and all other providers outlined in the Health System Entity Medical Staff Bylaws, policies, or related contracts. Assists in ensuring interpretation and compliance with the appropriate accrediting and regulatory agencies, while maintaining a working knowledge of the statues relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications.

Essential Job Functions

The following duties are mandatory requirements of the job

• Assisting with the coordination and monitor the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
• Organized and detail oriented.
• Assists with conducting thorough background investigation, research, and primary source verification of all components of the application file.
• Assists in identifying issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow up.
• Assists in processing requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
• Supports the Credentialing Director and Billing Director in responding to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
• Utilizes the credentialing database, optimizing efficiency, and performs query, report, and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act
• Assists with credentialing activities and credentialing process.
• Assists in the reappointment process which is initiated for each practitioner.
• Assist with the submission of provider credentialing information to health plans for inclusion in Prospect networks,
• Assist with coordinating credentialing activities with contracted CVO.
• Support the coordination of the provider verification/credentialing and re-credentialing processes for all clinical staff.
• Review CAQH database and Assist in ensuring providers are updating their information and data are compliant.
• Assist in ensuring that the credentialing practices adhere to organizational standards and current industry trends.
• Perform standard and routine document audits.
• Perform periodic audits of credentialing documents.
• Schedule fingerprint appointments for URAM employment candidates.
• Manage fingerprint information.
• Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified.
• Assists with managed care delegated credentialing audits; conducts internal file audits.
• Maintains database programs for credentialing.
• Assist, work with and/or inform the Billing Director of necessary changes per each insurance plan credentialed such as covering rights, line of business and any specific location addresses assigned to provide services.

The following duties are to be performed as assigned by the supervisor:

• Attendance provider meetings as needed
• Summary Report on credentialing status
• Communication with credentialing bodies

Education

• Bachelor’s degree
• 5+ years of Credentialing experience
• Knowledge of NCQA, URAC, JCAHO and CMS health standards a plus
• Proficient in Microsoft Word, Excel, and Outlook
• Excellent written and oral communication skills
• Superb Organizational skills
• Good administrative skills