JOB SUMMARY

Under the direction of the Credentialing Manager, the Credentialing & Privileging Coordinator is responsible for coordinating all aspects of the credentialing and/or recredentialing process as well as changes in privileges/specialty or demographic information for health care professionals practicing within Central Health. This position ensures health care professionals are appropriately credentialed and privileged, including ongoing maintenance and verification of current information on file and within the credentialing database, and other duties required to maintain compliance with regulatory and accreditation agencies and Central Health credentialing policies and procedures.

This position is considered Hybrid, which means that individuals in this position may work both at an approved Offsite location and Onsite at a primary location or multiple locations based on Business Needs.

JOB FUNCTIONS

Essential Functions

Reviews, screens, and completes initial credentialing and/or recredentialing and additional privilege request applications for completeness, accuracy, and compliance with federal, state, local, and Central Health regulations, standards, policies, and guidelines.

Performs and collects primary source verification (PSV) of all credentialing elements and validates the information to ensure accuracy.

Performs data entry of new applications in the credentialing database.

Communicates clearly with providers, their credentialing representatives, and leadership as needed to provide timely updates and responses on day-to-day credentialing and privileging issues as they arise.

Analyzes, identifies, and resolves discrepancies, time gaps, and other issues that could impact ability to credential healthcare practitioners.

Reports issues in a timely manner to Credentialing Manager for decision making in accordance with credentialing and privileging policies and federal, state, and local government and health plan standards.

Provides consistent and timely follow-up on all outstanding credentialing/re-credentialing files.

Processes provider demographic changes, ensuring appropriate documentation has been submitted with the changes, updating credentialing database and notifying health plans of changes.

Prepares and scans credentialing/re-credentialing files and other credentialing documentation and stores in appropriate locations.

Maintains knowledge of current requirements for credentialing and privileging providers.

Ensures all tasks and duties comply with all regulatory and accreditation standards including The Joint Commission standards, the National Committee Quality Assurance (NCQA) guidelines, and also Central Health policies and procedures.

Monitors and manages credentialing and recredentialing requirements to ensure all required renewals are on file within their required time frame.

Ensures timely entry, processing, and tracking of provider credentialing files.

Ensures all actions, job performance, personal conduct and communication always represent Central Health in a highly-professional manner.

Upholds and ensures compliance, confidentiality and adherence to all HIPAA guidelines and maintains a strict level of confidentiality for all departmental and healthcare provider information.

Adheres to company policies and procedures, as well as the overall mission and values of the organization.

Ensures that all work is done in a timely and accurate manner.

Works within established credentialing timeframes and notifies manager as to status and barriers preventing work being done in a timely and accurate manner.

Maintains strong working relationships with providers, health plan staff, other credentialing verification offices and any other stakeholders.

Develops and maintains favorable relationships with internal team members.

Ensures monthly ongoing monitoring of licenses and sanctions.

Audits disciplinary reports, OIG reports, and other reports as required and initiates the formal complaint procedure, when applicable.

Participates in staff meetings and recommends new approaches, policies and procedures to effect continual improvement in efficiency of the department and services performed.

Respond to emails timely and effectively.

Provides support to physicians, physician office staff, and company departments as necessary.

Assists with annual health plan delegated credentialing audits.

Cross trains within department to support credentialing operations (back-up support for credentialing files, vacation/PTO).

Participates in various educational/training as required.

Performs other job-related duties as assigned.

MINIMUM EDUCATION

High School Diploma 

MINIMUM EXPERIENCE:

2 years of experience in practitioner credentialing with a working knowledge of federal and state regulatory agencies and accrediting bodies (CMS, TJC, NCQA, etc.) Required

PREFERRED EXPERIENCE:

5 years of experience in a credentialing and privileging role with knowledge in either ambulatory, managed care, or hospital credentialing with strong knowledge of federal and state regulatory agencies and accrediting bodies (CMS, TJC, NCQA, etc.) Preferred