Identify, obtain and verify credentials for all licensed practitioners for initial credentialing and re-credentialing under the direction of the Provider Relations Coordinator. Prepare credential files for presentation to the Membership Committee and the Board of Trustees. Maintain electronic and hard-copy files to ensure all credentials are current.
Essential Duties and Responsibilities:
- Respond to requests for membership by sending out the appropriate membership packets.
- Process initial applications as received, verify education, training, hospital affiliations, peers’ letters of recommendation, board certification, licensure, national practitioner data bank (NPDB) and Medicare/Medical sanction information.
- Reviews packets and documentation for accuracy, follows up to obtain missing or incomplete items in a timely and professional manner.
- Process re-applications for providers due for re-credentialing every three (3) years.
- Ensure licensure for all practitioners is current at all times in the files. Proactively verifies licensure with the Licensing Boards for new credentialing applications, re-credentialing, upon sanctioning and additionally as needed.
- Prepare credentialing packets as needed for the Membership Committee.
- Create and maintain hard copy and computer files to ensure most current practitioner data is available.
- Identify need, develop, implement and maintain credentialing/re-credentialing reports.
- Prepare and distribute monthly physician rosters to designated individuals internally and externally as directed.
- Responsible for following Company, client policies and procedures, HIPAA and other regulatory guidelines in the handling of Personal Health Information (PHI).
- Responsible for regular and predictable on-site attendance.
- Perform related duties as required as assigned.
- Ensure work areas are clean, organized and policyholder information is kept secure.
- Attend meetings and training as necessary.
- Work in a team environment, ensuring team and individual goals are met.
- Handle special projects and duties as assigned.
Knowledge, Skills and Abilities required:
- Must be a self-directed individual who possesses high level organizational and time management skills.
- Strong analytical skills and demonstrates excellent attention to detail.
- Ability to communicate in a professional manner, possesses excellent oral, business writing and telephone skills.
- Ability to follow instructions and follow established departmental protocols and procedures.
- Ability to maintain professional demeanor, exercises tact and discretion. Highly ethical and maintains high level of confidentiality.
- Proficient in Microsoft Office applications including Word, PowerPoint, Outlook and Advanced Excel skills.
- Working knowledge client software and internal report-generating programs.
- Experience in meeting NCQA standards.
- Must be able to establish and maintain effective interpersonal skills with all Foundation staff, telephone and walk-in clientele.
- Ability to conform to an established work schedule and demonstrate high-level attendance in accordance with the Attendance/Absenteeism Policy.
Minimum Education and/or Experience, Certifications/Licenses required:
- Two years’ experience in the field of Health Care Credentialing,
- Knowledge of Medical Terminology preferred.
- Typing certificate verifying ability to type a minimum 40 words per minute dated within one year of application date.
Essential Physical Requirements and Tasks:
- Employee is constantly required to sit; talk; hear; use keyboard/ten key; and repetitive motion of hands.
- Employee is occasionally required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; and stoop, bend, kneel, squat or crouch.
- The employee must occasionally lift and/or push/pull up to 25 lbs.
- Specific vision abilities required by this job include close vision, distance vision and depth perception.
- Exposure to air-conditioned/heated office environment.
- Work in close proximity to others and experience low noise levels from office equipment and voices.
- Use of office equipment, such as telephone, computer, copy machine and fax machine.