Job Details

Job Description

***This is a hybrid position. In-person meetings, occasional on-site work***

The Credentialing Specialist is responsible for credentialing compliance with each entity's Medical Staff bylaws, rules and regulations, policies and procedures, The Joint Commission, NCQA, and federal and state regulations, as applicable to the customer. The Credentials Specialist is responsible for analysis of credentialing files, membership requests and renewals for all facilities where providers practice on behalf of FMOL, reappointment activities, malpractice enrollment and renewal, management and maintenance of supervision/collaboration status of Allied Health Professionals with respective state boards and payer enrollment. Relies on education, critical thinking skills, and judgment to accomplish job. Ability to process and manage applications. Works under general supervision. Creativity and some latitude is expected to complete responsibilities.

Responsibilities

1. Coordination
   1. Coordinates and provides appropriate guidance to the provider customers during initial credentialing, privilege delineation (as applicable), reappointment activities, malpractice enrollment and renewal, and payer enrollment in accordance with each entity's medical staff bylaws, rules and regulations, policies and bylaws, The Joint Commission, NCQA, federal and state regulatory standards, as applicable. Activities associated with this function include but are not limited to: management of applications, verification of credentials, monitoring various industry databases for evidence of potentially adverse information for leadership review, red flagging potentially adverse information for leadership review, identification of areas where practitioners may not meet privileging or membership criteria, management and maintenance of malpractice coverage for internal and external activities, as applicable, management and maintenance of supervision/collaboration status of Advanced Practice Professionals with respective state boards, and maintenance of enrollment with all payers, as applicable.
   2. Assures that all documentation reflects that required activities are undertaken by individual evaluators and leaders and that relevant information is communicated to the respective point of contact at each FMOL facility who retains responsibility for oversight, including their own manager. Notifies applicant, appropriate internal customer leader personnel and director of any actions taken.
   3. Upon receipt of a complete application, initiates information, collection, verification, and documentation process per established policies and procedures and cognitive analysis of all information received. Evaluates adequacy and quality and pursues additional information as necessary. Coordinates and facilitates review/recommendation and approval processes. Communicates relative information to applicant, appropriate hospital personnel, and appropriate FMOLHS personnel and establishes necessary files.
   4. Coordinates and participates in formal credentialing review/recommendation and approval processes for internal customers and payers, as needed. Maintains the CAQH, Apogee and FMOL Credentialing databases to ensure accurate information - Monitors expirables (DEA, CDS, licensure, medical malpractice insurance, board certification) and maintains and updates the credential file (electronic and/or hard copy).
2. Communication
   1. Effectively communicates issues and ongoing status of assigned work to Manager and others within the department.
   2. Assures that the Credentials Program operates effectively and efficiently. Supervises and acts as a supportive resource to the providers and users. Assures that all providers have the tools and training necessary to perform their job functions. Assists to ensure that work flows, information systems, and credentialing policies and procedures are current and appropriately maintained.
   3. Maintains open and effective communication with credentialing staff at other facilities.
3. Technical Tasks
   1. Provides guidance, technical and administrative support to credentials committee and FMOLHS departmental customers, including planning and organizing supporting documentation for committee activity. Also develops methods for addressing committee needs in a timely manner.
   2. Maintains adherence to confidentiality standards established within the department and in accordance with legal, ethical, and departmental policies. Ensures data security and confidentiality by use of confidential password system, appropriate labeling of information and storage, and appropriately secured cabinets and drawers.
4. Other Duties as Assigned
   1. Performs other duties as assigned or requested such as reception, filing, correspondence or other activities to support the general operations of the OLOLPG CVO Department.

Qualifications

Experience - 4 years experience in a healthcare entity that includes payor interactions and/or credentialing plus 1 year credentialing experience performing all the functions of the credentialing process (undergrad degree may substitute for 4 years' experience requirement)
Education - High school diploma
Special Skills - Microsoft Applications, Computer Literacy, Data Entry, Internet Searching Abilities