Primary responsibility involves auditing credentialing files after internal and Gemini processing to ensure that all verifications are clearly bookmarked in accordance with established Standard Operating Procedure (SOP) documents, dates are correct and in accordance with NCQA and regulatory guidelines and necessary documents are completed and attached.
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Audits credentialing files after internal and Gemini processing for completeness
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Audits credentialing files after internal and Gemini processing for correct date validations
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Ensures that all completed credentialing files are bookmarked correctly in accordance with the established Standard Operating Procedure (SOP)
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Documents auditing results and notifies respective credentialing coordinator of results and/or areas that require correction
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Submits quarterly HICE credentialing reports to contracted health plans
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Identifies issues that require additional investigation and evaluation; validates discrepancies and ensures appropriate follow-up.
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Responds to inquiries from health plans and provider offices/clinics; interfaces with internal and external customers on day-to-day credentialing issues as they arise.
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Optimizes efficiency with document generation and reporting.
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Monitors the initial, recredentialing and expirable processes for all delegated providers including allied health professional staff.
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Enters primary source documentation to home grown credentialing database sPHERICAL, Gemini’s G1 system, and symplr based on established workflows.
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Remains informed about changes in regulations and NCQA standards related to credentialing.
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Attends MPM Credentialing Committee and HICE meetings as requested.
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Assist Credentialing Coordinators with chart completion as time permits.
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High school diploma or GED
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At least 2 years’ experience with hospital medical staff or managed care credentialing position.
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NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing the above certification highly preferred.
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Strong written and oral communication skills.
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Knowledge of healthcare credentialing procedures and standards.
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Ability to multitask in fast paced environment.
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Sharp attention to detail.
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Ability to analyze, interpret and prepare reports.
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Proficiency with Microsoft Office 355 Programs; primarily Word and Excel
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EZ-CAP® and Smartsheet knowledge a plus.
