Responsible for collaborating with CVO, credentialing staff and provider services to coordinate, monitor and maintain the credentialing and re-credentialing process for Health Delivery Organizations (HDO).
Duties and Responsibilities
- Coordinates all activities related to network credentialing including, but not limited to application completeness and maintenance for HDOs.
- Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
- Ensures that all facilities meet standards related to quality improvement programs and personnel issues.
- Verifies that providers are accredited by an appropriate accrediting agency before submission for HDO credentialing process and every three years thereafter.
- Oversees preparation of HDO credential files for completion and presentation to MedPOINT’s Credentialing Committee.
- Responds to inquiries from health plans and provider offices/clinics; interfaces with internal and external customers on day-to-day credentialing issues as they arise.
- Optimizes efficiencies with document generation and reporting.
- Coordinates primary source verification process for HDOs with Gemini Diversified Services (CVO).
- Enters primary source documentation in home grown credentialing database.
- Participates in credentialing committee meetings (monthly and ad hoc).
- Collects and verifies quarterly provider rosters from HDOs.
- Assists with P & P development in accordance with NCQA guidelines for HDO credentialing.
- Contributes information to any corrective action plans related to HDOs.
- Assists with non-HDO credentialing functions as requested by leadership as time permits.
- Performs miscellaneous job-related duties as assigned and requested.
Minimum Job Requirements
High school diploma or GED; at least 1 year experience with hospital medical staff or managed care credentialing including HDO processing. NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing the above certification highly preferred.
Knowledge, Skills and Abilities Required
- Strong written and oral communication skills.
- Excellent presentation and analytical skills.
- Ability to analyze, interpret and prepare reports.
- Proficiency with Microsoft Office Programs; primarily Word and Excel 2013 or higher.
- Knowledge of all aspects of credentialing including HDO Credentialing.
- Ability to multitask and work well as a team.
- Ability to work independently and productively in a remote environment.
- EZ-CAP® knowledge a plus.