Job Summary: The Credentialing Coordinator is responsible for verifying and maintaining the credentials of healthcare providers within the organization. They ensure compliance with regulatory standards and organizational policies related to credentialing and privileging. The Coordinator works closely with healthcare providers, regulatory agencies, and internal departments to facilitate the credentialing process efficiently.

Responsibilities:

1. Credential Verification:

   • Verify the credentials of healthcare providers, including education, training, licensure, certifications, and professional experience.
   • Ensure accuracy and completeness of credentialing documentation.
   • Conduct primary source verification of credentials through direct contact with issuing institutions and agencies.

2. Credentialing Process Management:

   • Oversee the credentialing process for new hires, reappointments, and privileging.
   • Maintain up-to-date credentialing files for all providers.
   • Ensure compliance with organizational policies, bylaws, and regulatory requirements.
   • Coordinate with internal departments such as Human Resources, Medical Staff Services, and Compliance to streamline the credentialing process.

3. Provider Enrollment:

   • Facilitate provider enrollment with insurance plans, Medicare, and Medicaid.
   • Submit and track enrollment applications, ensuring timely completion.
   • Coordinate with billing and revenue cycle teams to ensure accurate provider enrollment data.

4. Database Management:

   • Maintain credentialing and provider databases, ensuring data accuracy and integrity.
   • Generate reports and analyze credentialing data as needed for internal audits, accreditation, and performance improvement initiatives.

5. Communication and Collaboration:

   • Serve as the primary point of contact for credentialing inquiries from healthcare providers, staff, and external agencies.
   • Collaborate with credentialing committees and medical leadership to address credentialing issues and concerns.
   • Communicate credentialing status updates to stakeholders, including providers and leadership.

6. Continuous Improvement:

   • Identify opportunities to improve credentialing processes and procedures.
   • Participate in quality improvement initiatives related to credentialing and provider enrollment.
   • Stay updated on industry trends, regulations, and best practices in credentialing and privileging.

Qualifications:

• Bachelor's degree in healthcare administration, business administration, or related field (preferred).
• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) designation (preferred).
• Previous experience in healthcare credentialing or medical staff services.
• Knowledge of credentialing standards, regulations, and accreditation requirements (e.g., NCQA, TJC, CMS).
• Proficiency in credentialing software and database management.
• Strong attention to detail, organizational skills, and ability to manage multiple tasks simultaneously.
• Excellent communication and interpersonal skills.
• Ability to work independently and collaboratively in a fast-paced environment.

Note: The specific responsibilities and qualifications may vary depending on the healthcare organization and its size, specialty, and regulatory requirements.