Job Summary :

Independently requests and reviews primary source information and verifications. Identifies and plans for resolution of moderately complex gaps in vendor relationships and escalates, as needed.

Applies and begins to suggest improvements to credentialing and privileging processes. Evaluates moderately complex practitioner sanctions.

Participates in surveys and audits of credentialing entities. Facilitates cost-effective due process. Conducts audits of data between different departments.

Conducts the facilitation and orientation and training to newly appointed physician leaders. Develops moderately complex informational documents.

Maintains working relationships with key stakeholders. Maintains awareness of policies and provides moderately complex consultations.

Processes moderately complex provider enrollment information. Gathers and independently communicates relevant information to appropriate parties.

Proactively ensures, guides others, and improves processes to enact control of data systems and applications. Independently analyzes data.

Maintains moderately complex structures database structures and data.

Essential Responsibilities :

• Promotes learning in others by proactively providing and / or developing information, resources, advice, and expertise with coworkers and members;
• builds relationships with cross-functional / external stakeholders and customers. Listens to, seeks, and addresses performance feedback;
• proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses;
• leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities;

adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes.

Facilitates team collaboration to support a business outcome.

• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions;
• encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and / or externally to achieve effective business decisions;

provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results.

Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines.

Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.

• Participates in training and regulatory awareness by : may be independently facilitating orientation and training to newly appointed physician leaders for effective oversight and management of their departments credentialing, proctoring, privileging and reappointment processes;
• developing moderately complex informational / educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies;
• independently developing and cultivating working relationships with key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making;

and maintaining awareness of current internal policies and relevant external regulations and starting to provide moderately complex consultative expertise to internal parties.

• Ensures quality assurance, improvement, and resolution by : independently obtaining and evaluating moderately complex practitioner sanctions, complaints, and adverse data to ensure compliance;
• participating in ongoing assessments of moderately complex governing documents (e.g., bylaws / rules and regulations / policies and procedures) to ensure continuous compliance;
• participating in surveys and audits of credentialing entities (e.g., CMOs, delegates and health plans for NCQA); independently facilitating efficient and cost-effective due process that complies with internal fair hearing and appeals policies and external legal and regulatory requirements;
• identifying and escalating and preparing moderately complex adverse actions / issues (e.g., sanctions and complaints) to the credentialing committee taken against a practitioner / provider in accordance with applicable law and contractual requirements to the necessary parties;

and independently conducting audits and reconciliations of data between different departments, monitoring of credentialing and contracting.

• Processes provider enrollment by : gathering and performing detailed and thorough review of the moderately complex information used to submit the enrollment applications;
• independently preparing and submitting data and applications to the contracted and government payors in a manner commensurate with their expectations, policies and accreditation standards;

independently communicating enrollment status to all stakeholders in a clear and timely manner; and may be notarizing public documents.

• Conducts primary source verification and management by : independently requesting, obtaining, and reviewing information from primary source verifications to evaluate applications and provided sources for alignment;
• identifying moderately complex gaps and opportunities in vendor relationships, and escalating to manager as appropriate;
• independently identifying, investigating, creating, and executing plan for resolution of inaccurate primary source process, verifications, applications, and adverse information, escalating as appropriate;
• independently verifying and documenting expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards, with limited direction;

and serving as main point of contact for external queries regarding practitioners status, responding in a timely manner.

• Conducts database management by : independently maintaining moderately complex structures and data within a computerized data base of physician data for use in the credentialling and appointment process, in alignment with department guidelines.
• Applies and ensures control and application of data systems by : applying strategies to regularly maintain data structures, system functions, creations of workflows, portal management and coordinating the access and controls of data;

interpreting guidelines to enact auditing, assessing, procuring, implementing, effectively utilizing, and maintaining practitioner / provider and delegated credentialing processes and information

Last updated : 2024-04-23