Job Description

The Credentialing Specialist I demonstrates excellent customer service performance in that his/her attitude and actions are always consistent with the standards contained in the Vision, Mission and Values of Covenant Health Care and the commitment to Extraordinary Care for Every Generation.

The primary role of the Credentialing Specialist I is to complete, both, delegated and traditional credentialing files accurately, and efficiently. This position will be responsible for submitting initial credentialing applications, and all associated follow up on those applications. The Credentialing Specialist I will also be responsible for verifying the accuracy of all submitted credentialing information, and for creating, or auditing accurate Primary Source Verification (PSV) files for delegated credentialing through CAQH and maintain NCQA Credentialing/Recredentialing Accreditation.

Responsible for implementation and oversight of all activities related to physician credentialing, re-credentialing, and delegation.

Responsible for compliance to delegation agreements.

Responsible for the maintenance of Credentialing policies and procedures.

Remain current with credentialing requirements mandated by external review agencies (e.g., NCQA, HFAP) and/or state and federal regulations. Collaborate with leader to modify delegation processes to ensure continued compliance with such requirements.

Maintains detailed knowledge of NCQA and a cursory knowledge of URAC and HFAP credentialing requirements.

Monitors regulatory sources to stay informed of rapidly changing rules and regulations that relate to credentialing processes.

Reviews and processes all provider applications to Primary Partners (PO) and Covenant HealthCare Partners (PHO).

Analyzes and resolves provider file issues, tracks progress on network management, and produces weekly reports.

Reviews and analyzes provider file changes.

Responds to provider inquiries received by letter, phone, or internal departments.

Administers Re-credentialing of network providers.

Reviews and monitors provider complaint and grievance files.

Attends Credentialing Committee meeting and records meeting minutes to comply with NCQA requirements.

Ability to apply common sense understanding to carry out moderately complex, multi-step instructions and make appropriate independent decisions as necessary.

Maintains close contact with Billing Department to provide updates on new hires, terminations, approvals from MCOs, and any other information billing department could need from credentialing.

Maintains and updates the providers MD Staff credentialing profiles as outlined in the PHO Standard Operating Procedures and/or policy.

Interact with various cross functional groups, complete the required auditing and reporting related to credentialing delegation, and ensure adherence with NCQA requirements for credentialing and recredentialing.

Collaborate with the various departments to conduct the timely credentialing delegation audits Develop the post-audit reports based on audit findings and communicate those to the delegated entities, and credentialing leader.

Ensure compliance with delegation monitoring and oversight requirements for credentialing functions.

Adhere to policies and procedures related to delegation maintenance.

Identify process improvement opportunities that organizationally decrease cost, improve quality, and increase efficiency.

Maintain strict confidentiality of practitioner, company, and personnel information.

Collaborate with Credentialing, Billing, and IT teams for seamless practitioner onboarding.

Manage group and practitioner’s attestations and required documents in credentialing database.

Communicate to key stakeholders updates regarding clinical practice sites (office relocations, facility revisions, and new facility start-up).

Maintain the credentialing database tracking for group and practitioner address revisions, terminations and communicate changes with teammates.

Performs miscellaneous job-related duties as assigned.

Represents department in required meetings as it relates to credentialing.

Maintains an expert level knowledge of the credentialing and recredentialing process as evidenced by maintaining CPCS Certification. This includes ensuring that all policies and procedures accurately represent all regulatory requirements.

EDUCATION/EXPERIENCE REQUIREMENTS

Associates degree required, Bachelor’s degree preferred. In lieu of Associates degree, a minimum of two (2) years medical field experience required and willing to obtain an Associates degree within three (3) years. 

Two (2) years recent experience in physician practice preferred.

Knowledge of hospital-based workflow and physician office-based experience.

Experience with electronic credentialing software: MD Staff or other credentialing software.

Experience as a participant in continuous process improvement preferred.

Excellent computer knowledge and capability to use computer required, i.e., Microsoft Word, Excel.

KNOWLEDGE/SKILLS/ABILITIES

Achieve the process of change by recognizing and communicating the need.

Detailed and accurate data input into MD Staff or other credentialing software as outlined in policy.

Promote and build commitment for change by championing, leading, and helping others.

Express thoughts clearly, concisely, and effectively both verbally and in writing.

Ability to communicate upward, downward and across the organization.

Encourage the open expression of ideas and opinions of others.

Ability to adapt behavior in response to new information or changing circumstances.

Open to change and new information, ideas, methods, or approaches.

Work and collaborate effectively with others in unstructured or dynamic environments and adjust the original objective or plan to allow for the best possible results.

Understand information technology concepts, key functions, terminology, and work products; effectively utilizes information technology, MD Staff.

Knowledge of CAQH and NCQA.

Understand legal concepts, key functions, terminology and the roles and responsibilities of legal counsel.

Understand current performance improvement concepts and ideas, such as setting goals, implementing systemic changes, measuring outcomes, and optimizing resources to meet the needs of the organization.

Exhibit confidence and professional diplomacy while identifying, organize, facilitating and/or sustaining mutual beneficial partnerships with people of all levels internally as well as externally.

Present in a confident, clear, and enthusiastic manner when addressing people in a small or large group.

Demonstrate a sound knowledge of the subject matter.

Effectively use various audio-visual media for presentations.

Inspire trust and confidence among stakeholders through reliability, authenticity, and accountability.

Displays a credible presence and positive image when representing the organization.

Organize work, set priorities, and determine short- or long-term goals, and strategies to achieve them.

Commit to continuous performance and process improvement.

Establish productive, cooperative relationships with peers, management, and stakeholders both internal and external to the organization.

Encourage and facilitate cooperation, trust, and group identity; and build commitment, team spirit, and strong relationships.

Computer and word processing ability including MD Staff, Microsoft Word, and Excel.

Typing, ability to communicate well with others, proficiency in listening, writing, and speaking.

Excellent written communication skills for constructing minutes and correspondence, and excellent verbal skills for communicating individually and in group meetings.

Strong interpersonal, diplomatic, and organizational skills. Demonstrates ability to maintain information in a confidential manner.

Customer Service focused on all daily activities.

Demonstrates ability to make sound independent decisions within boundaries of policies and procedures.

WORKING CONDITIONS/PHYSICAL DEMANDS

Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.

Constant sitting.

Frequent carrying, handling, tasting, and smelling.

Frequent lifting 0-10 lbs.

Occasional lifting 11-50 lbs.

Occasional standing, walking, talking and hearing, pushing, pulling, stooping, kneeling, and squatting.

Constant near vision, far vision, depth perception, color vision and field of vision.

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