POSITION SUMMARY / RESPONSIBILITIES
Implements and oversees the credentialing and recredentialing program of practitioners and providers, including entities delegated for credentialing, in accordance with regulatory and accreditation standards.
Monitors regulatory, contractual and accreditation standards and implements policy and procedural changes, as appropriate.
Collaborates with consortium health plans in the review and coordination of contractual requirements for the verification process by the state Credentialing Verification Organization.
Coordinates research and Credentialing Committee reports of initial practitioners who have issues with their credentials and reports from the licensing and monitoring organizations.
Coordinates with the Chief Medical Officer or designee for administration of the Credentialing Committee and Committee actions.
EDUCATION / EXPERIENCE
An associate degree in a health care related or business management field or five years of equivalent experience related to the duties and responsibilities as specified is required.
Excellent written and oral communication, problem-solving, organizational skills, statistical and analytical abilities are required.
Knowledge of accreditation credentialing standards (such as NCQA), federal, state and regulatory agency requirements with reference to verification of physician / allied health professional credentials is required.
At least five years of supervisory experience in a managed care setting with exposure to multiple product lines and communication with regulatory agencies is preferred.
LICENSURE / CERTIFICATION
NAMSS Certification as Certified Provider Credentials Specialist (CPCS) is preferred.
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