Credentialing Specialist

POSITION PURPOSE
Under general supervision of the Director of Medical Staff Services, the Credentialing Specialist is responsible for credentialing, reappointment processing and maintenance of the files of all individuals who are permitted by the Medical Staff Bylaws and hospital to provide patient care services independently and who have clinical privileges, whether or not they are members of the Medical Staff;
maintaining and modifying the physician and allied health professional databases;
development and production of reports pertaining to the medical staff provision of support, as needed, to medical staff offices. Manages and coordinates physician and allied health professional activities in accordance with Bylaws, Rules &
Regulations, CIHQ and other regulatory standards and serves as a primary resource as needed.
Under general supervision of the Director of Revenue Cycle, the Credentialing Specialist is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing packages as required by hospitals, Medicare, Medicaid and other healthcare entities. The Specialist will work closely with the billing staff to identify and resolve any denials or authorization issues related to provider credentialing.
ESSENTIAL JOB FUNCTIONS
Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.
1. Processes applications and credentials medical staff applicants, Allied Health applicants, and Locum Tenens applicants.
2. Assists in the reappointment process for all medical staff categories.
3. Assists with coordinating all monthly physician on-call calendars and maintains a permanent record of all on-call calendars. Updates downtime book as needed.
4. Assist with distributing meeting calendar to department managers and active medical staff members. Attends and takes minutes for Credentials Committee. Attends and assists with Tumor Board.
5. Prepares agenda, information packets, and coordinates arrangements for the Credentials Committee;
notifies participates of meeting.
6. Maintains confidential files on all medical staff members, reflecting current status, i.E., category, board certification, privileges, attendance records, CME activities, publications and committee participation.
7. Maintains records, files, policies and procedures as required by Joint Commission Standards;
revises same as indicated by CIHQ on an ongoing basis.
8. Assists in preparation for CIHQ Survey working closely with the Medical Staff to ensure compliance with standards.
9. Assists the Director in processing, and maintaining credentialing and privileging activities.
10. Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications
11. Maintain internal provider grid to ensure all information is accurate and logins are available
12. Update each provider’s CAQH database file timely according to the schedule published by CMS
13. Apply for and renew annually all provider licenses;
Professional, DEA, Controlled Substance
14. Complete revalidation requests issued by government payers
15. Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid
16. Complete re-credentialing applications for commercial payers
17. Credential new providers and re-credential current providers with hospitals at which they hold staff privileges
18. Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases
19. Maintains databases, preparing reports routinely.
20. Assists in care and maintenance of department equipment and ordering supplies.
21. Abides by the HMH Legal Compliance Code of Conduct.
22. Maintains a safe work environment and reports safety concerns appropriately.
23. Maintains confidentiality and appropriate handling of PHI.
24. Performs all other related duties as required and assigned.
Requirements
QUALIFICATIONS
Education:
High school diploma or GED required.
Experience:
3-5 years hospital payer credentialing/Payer Enrollment experience preferred.
License/Certifications:
None required, CPCS or CPMSM certification preferred.
Required Skills:
Excellent interpersonal, problem solving, and written and oral communication skills.