Overview

The Credentialing Specialist provides administrative assistance and verifies licenses and credentials for medical and healthcare personnel at AMMD and Men’s Health Foundation. The incumbent is also responsible for ensuring that all related facilities are credentialled and compliance with health applicable health plans.

Duties include keeping detailed records of medical staff members, maintaining databases and ensuring staff members possess legal licenses and credentials to work in their chosen fields; ensuring that every staff member is legally licensed and/or credentialed and up to date with the latest medical policies and procedures.

Essential Functions and Responsibilities

• Create and maintain licensing, credentials, and insurance records for oncoming and current staff.
• Research updated state and federal regulations and policies for delivering health care services.
• Release information to requesting agencies and public inquiries when required by law.
• Help develop internal credentialing processes.
• Monitor license and credential expiration dates and advise staff members of required “renew by” dates.
• Ensure the facility and staff members comply with regulatory and accrediting health plans and institutions.
• Maintain up-to-date records on facility credentialing requirements per credentialing body.
• Work with compliance facilities departments to ensure facilities credentialing standards are met per certifying body.
• Compiles and maintains current and accurate data for all providers.
• Completes provider credentialing and re-credentialing applications; monitors applications and follows up as needed.
• Maintains copies of current state licenses, DEA certificates, malpractice coverage, and any other required credentialing documents for all providers.
• Maintains corporate provider contract files.
• Maintains knowledge of current health plan and agency requirements for credentialing providers.
• Sets up and maintains provider information in online credentialing databases and systems.
• Tracks license and certification expirations for all providers to ensure timely renewals.
• Monitors and reports expirations on required operational licenses (e.g CLIA, business licenses, medical waste etc.).
• Ensures practice addresses are current with health plans, agencies, and other entities.
• Tracks license, DEA and professional liability expirations for appointed ASC providers.
• Maintains ASC appointment files, and information in credentialing database.
• Audits health plan directories for current and accurate provider information.
• Manage credentialing to ensure that applications are done in accordance with regulations, and in a timely manner.
• In charge of monitoring the credentialing process and analyzing the billing data to identify time gaps and other issues that could adversely impact the ability to credential and enroll practitioners; ultimately avoiding revenue loss.
• Discovers and conveys problems to CMO for sound decision making in accordance with Medical Staff Bylaws, credentialing policies and procedures, federal, state, local and government/insurance agency regulations.
• Track outcomes, analyze results, and provide regular reports regarding the status of credentialing to Professional Services and Faculty Practice leadership.
• Work closely with departmental leadership, and key stake holders to identify key areas of improvement.
• Reconcile provider enrollment data with payor rosters as needed.
• Incumbent will be responsible for promoting best practices and handle credentialing related projects, which will require the specialist to develop flow charts, check list, tip sheets, etc.

QUALIFICATIONS:

Education:

• 1. Associate degree Required; Bachelor’s degree Preferred
• 3 Years work experience
• Knowledge of provider credentialing and its direct impact on the practice’s revenue cycle.
• Ability to use independent judgment and to manage and impart confidential information.
• General Business Office
• Software: Microsoft Office, EPIC, Intermediate Excel Skills Preferred

Skills:

Language Skills

Must be able to read, write and speak the English language fluently. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Must have the ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public in person.

Mathematical Skills

Ability to calculate figures and amounts such as dollar totals, monetary conversions, discounts, interest, fractions, decimals, percentages, area, and volume.

Reasoning Ability

Ability to solve technical and practical problems and deal with various intangibles in situations where only limited communication, support, information, and access exist. Ability to interpret various instructions furnished in written, oral, diagram, or schedule form.

Computer Skills:

Must have good computer skills and be proficient in the use of systems to complete correspondence, documents, spreadsheets, and presentations, such as Microsoft Outlook and Office, Word, Excel and PowerPoint, and Adobe Acrobat.

Physical Demands:

The physical demands described here represent those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or listen. The employee is mostly required to sit; use hands to finger, handle, or feel and reach with hands and arms. The employee is constantly required to stand and walk. The employee may be required to climb ladders or stairs, be in high spaces, and/or balance, stop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

While performing the duties of this job, the employee is in an office environment, workstation, or shared space. The noise level in the work environment is occasionally moderate with occasional high volume.