Credentialing Specialist

A. POSITION SUMMARY

Supervised by the Human Resources Officer, the Credentialing Specialist is responsible for originating/processing all provider applications for initial privileging, including temporary privileging as applicable, and for full appointment/reappointment to the FCCH Clinical Staff; this activity must be conducted in accordance with FCCH bylaws/policies/procedures, The Joint Commission standards, and State and Federal regulations to assure that only qualified professionals provide care at FCCH. The position includes all support for the application to and diligent follow up with external insurance organizations/other entities to ensure credentialing as a billable provider, and support for continuous provider licensing, to include licenses with state practice boards and federal DEA/state CSR licensing, as appropriate.

B. ESSENTIAL DUTIES AND RESPONSIBILITIES

• Initiate, review and process provider credentialing and privileging applications while adhering to all relevant guidelines, policies and procedures;
• Maintain provider credentialing files/e-files and/or databases with current and accurate information; analyze and resolve provider file issues;
• Coordinate, in concert with other appropriate FCCH staff, appropriate responses to insurer requests for facility credentialing/re-credentialing;
• Produce queries and reports to track the efficiency and effectiveness of the process;
• Ensure continuous required provider licensing, as applicable, and provide regular updates of provider licensing status;
• Ensure work standards are of the highest level, and managed to meet applicable internal and external deadlines;
• Forecast and prepare for upcoming reappointments/other applicable deadlines, and ensure all documentation is preserved;
• Participate in recurring presentations of provider staff credentialing/licensing status to various committees, board members and others, in partnership with clinical directors;
• Coordinate and communicate appropriately with all required insurers, including Medicaid and Medicare, and with other critical external partners, including the University of New Mexico Health Sciences Center;
• Maintain excellent communication with all FCCH providers and correspond as needed to obtain required information from/respond to inquiries received, by letter, telephone, and/or e-mail, on position-related activities;
• Review and verify incoming and outgoing documentation for completeness, accuracy, and compliance with established policies/procedures and best practices;
• Resolve or assist in the resolution of process-related procedural problems and/or inquiries received from FCCH health center/department representatives, insurers and/or providers;
• Gather information, conduct basic analysis, and assist in the development of problem-solving, as indicated;
• Perform specific research/investigation into credentialing-related operational issues, as requested;
• Perform miscellaneous job-related duties as assigned;

C. MINIMUM EDUCATION AND EXPERIENCE

• At least 4 months of directly related experience in credentialing & privileging services;
• Functional working knowledge of/expertise in using Microsoft Office Suite;
• Billing experience for multiple disciplines; medical primary care, dental and behavioral health;
• Billing experience in multiple reimbursement methodologies such as PPS (Prospective Payment System), FFS (Fee for Service) third party billing agreements. Including In-Network and Out of Network claims submissions and aged accounts receivable;

D. KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED

• Knowledge of principles and practices of credentialing;
• Effective oral and written communication skills;
• Excellent interpersonal skills;
• Ability to analyze and solve problems;
• Knowledge of database management;
• Knowledge of skills in scheduling and organizing, managing multiple priorities, telephone techniques and using computer databases;
• Excellent follow-through skills;
• Knowledge of laws, regulations, methods, and techniques in area of specialty;
• Knowledge of credentialing administration principles and procedures;
• Skill in examining and re-engineering operations and procedures, formulating policy, and developing and implementing new strategies and procedures;
• Convincing evidence of a service orientation;
• Knowledge of customer service standards and procedures;
• Program planning and implementation skills;
• Ability to foster a cooperative environment;
• Ability to communicate effectively, both verbally and in writing, with various internal and outside entities;
• Ability to exercise good judgment in appraising difficult situations and in making appropriate decisions;
• Ability to maintain confidentiality of records and information;
• Ability to work with computer software provided for/designed to support the position;
• Ability to work in a team setting with a variety of First Choice personnel;
• Knowledge of and familiarity with compliance programs, and ability to cooperate fully and comply with laws and regulations;

E. PHYSICAL CHARACTERISTICS/WORKING CONDITIONS

A person in this position has sufficient time to complete most tasks although under pressure depending on organization demands. There are frequent opportunities to relax from any physical exertion or to change position in work activities.

1. Physical Effort and Dexterity: Good dexterity to operate personal computer, and basic office equipment. Moderate physical activity expected. Requires handling of average-weight objects up to 25 pounds or standing and/or walking for more than four (4) hours per day.
2. Machines, Tools, Equipment required to be operated: office machines and personal computers for word processing, data entry and retrieval.
3. Visual Acuity, Hearing, and Speaking: Must be able to communicate clearly and accurately for work and safety compliance, including ability to read computer monitors.
4. Environment/Working Conditions: Work is mostly inside a clinic in a controlled environment. Normal clinic safety precautions and practices are required. Position may require travel throughout the Albuquerque metropolitan area. Work regularly scheduled Monday-Friday, although weekends may be required to meet deadlines.

This description lists the major duties and requirements of the job and is not all

inclusive. Applicants may be expected to perform job-related duties other than those

contained in this document and may be required to have specific job-related knowledge

and skills.