Responsible for collaborating with CVO, credentialing staff and provider network operations to coordinate, monitor and maintain the credentialing and re-credentialing processes. Responsible for the accuracy and integrity of the credentialing database system and related systems. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statutes and laws relating to credentialing. Prepares files for monthly credentialing committee and health plan audits. Works under the supervision of the Credentialing Leadership team.
- Leads, coordinates and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
- Identifies issues that require additional investigation and evaluation; validates discrepancies and ensures appropriate follow-up.
- Prepares credentialing files for completion and presentation to MedPOINT’s Credentialing Committee.
- 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.
- Optimizes efficiency with document generation and reporting.
- Monitors the initial, recredentialing and expirable processes for all delegated providers including allied health professional staff.
- Handles pre-audit and preparation functions to health plan audits.
- Coordinates primary source verification process with Gemini Diversified Services (CVO).
- Enters primary source documentation to home grown credentialing database sPHERICAL, Gemini’s G1 system, and symplr once onboarded.
- Bookmarks returned files in accordance with MPM approved process.
- Keeps informed about changes in regulations and NCQA standards related to credentialing.
- Communicates directly with professionals to obtain necessary information.
- Attends MPM Credentialing Committee and HICE meetings as requested.
- Performs miscellaneous job-related duties as assigned and requested.
- High school diploma or GED
- At least 2 years’ experience with hospital medical staff or managed care credentialing position.
- NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing the above certification highly preferred.
- Strong written and oral communication skills.
- Knowledge of healthcare credentialing procedures and standards.
- Ability to multitask in fast paced environment.
- Sharp attention to detail.
- Ability to analyze, interpret and prepare reports.
- Proficiency with Microsoft Office 355 Programs; primarily Word and Excel
- EZ-CAP® knowledge a plus.
