Credentialing Specialist

JOB SUMMARY :

Coordinates all activities associated with credentialing and privileging of medical, dental, and mental health providers.

Maintains policy, procedures and data to support the credentialing and privileging function.

MAJOR DUTIES AND RESPONSIBILITIES :

Compliance, Policy, and Procedures

• Maintains and recommends updates to CBHS' credentialing and privileging policies according to applicable regulations, accreditation requirements or decisions of CBHS' leadership.
• Maintains, implements, or updates CBHS' credentialing and privileging procedures for medical, dental and behavioral health providers.
• Works closely with the Chief Medical Officer, VP Behavioral Health and Human Resources (HR), and Director, Dental Services regarding policy and procedures for credentialing and privileging.
• Maintains records to support the credentialing function and comply with applicable accreditation standards, regulations, or provisions of contracts with payers.

This includes a database of all relevant provider information such as licenses, re-credentialing or re-privileging anniversary dates, etc.

Checking, Examining, and Recording

Works closely with HR Department to ensure that all necessary credentialing information is received prior to new hire start date.

After initial hiring and verification of information by the Human Resources Department, maintains and performs as necessary primary source verification of all licenses / certifications, obtaining information from the National Practitioner Databank, Office of Inspector General, American Medical Association, or other relevant organizations.

Alerts Vice President of HR to any adverse findings immediately.

• Maintains a public listing of all insurance plans with which all providers participate. Workplace Computers and Equipment
• Manages the on-line National Provider Identifier (NPI) enumerator system. Assigns NPI numbers to new provider hires; updates existing NPI information for new hires.
• Manages on-line Council for Affordable Quality Healthcare (CACH) database Communication
• Responds to inquiries from colleagues such as billing & finance staff, providers or from external sources to provide credentialing information.

Coordinates audits with organizations reviewing our credentialing and privileging policy and procedure Planning and Organizing

• Coordinates periodic meetings of the Medical Review Committee in conjunction with the Chief Medical Officer Teamwork
• When staff are absent in the HR department assists as requested with performing initial verification of information
• Assists billing staff as necessary regarding NPI and other enrollment discrepancies.
• Assists billing manager in resolving discrepancies related to credentialing or panel participation.
• Provides periodic education to clinical departments on credentialing requirements
• Assists the HR department in resolving issues related to providers' status of up-to-date documentation

Analytical and Critical Thinking

• Coordinates credentialing with insurance companies, hospitals, or other organizations
• Processes carrier enrollment applications for new provider hires to include Medical, Mental Health and Dental providers, and mid-level providers such as CRNPs.

Follows up to ensure receipt of applications.

• Processes renewals and updates to ensure continuous participation in insurance plans by applicable staff
• Processes providers' applications for privileges at hospitals or other organizations with which CBHS works
• Processes re-credentialing and other information requests by hospitals or other organizations with which CBHS works.
• Performs other duties as assigned

SKILLS AND ABILITIES :

• Functional understanding of insurance carrier requirements, Medicare, Medicaid and other entitlement programs.
• Excellent organization skills for record keeping and for work flow
• Ability to maintain confidential information
• Good word processing skills
• Working knowledge of credentialing software or other database applications.
• Expertise in MS Word, Excel, and Access.

EDUCATION AND / OR EXPERIENCE :

• Required : High School graduation
• Preferred : A two-year Associate's Degree
• Desired : Specialized training on credentialing and privileging in health care organizations.
• Required : Experience working in a health care setting (ambulatory, hospital, long term care) in a position that provided the incumbent understanding of the credentialing and privileging process;

or experience working for a health insurance company in a position that provided the incumbent understanding of the credentialing and privileging process.

WORKING CONDITIONS / PHYSICAL DEMANDS : Work is typically performed in an office environment