Credentialing & Privileging Coordinator

Overview

Under the direction of the Credentialing Manager, the Credentialing Coordinator is responsible for coordinating all aspects of the credentialing and/or recredentialing process as well as changes in privileges/specialty or demographic information for health care professionals practicing within CommUnityCare health centers. This position ensures health care professionals are appropriately credentialed and privileged, including ongoing maintenance and verification of current information on file and within the credentialing database, and other duties required to maintain compliance with regulatory and accreditation agencies and CommUnityCare credentialing policies and procedures.

Responsibilities

Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations):

• Reviews, screens, and completes initial credentialing and/or recredentialing, and additional privilege request applications for completeness, accuracy, and compliance with federal, state, local, and CommUnityCare regulations, standards, policies, and guidelines.
• Perform and collect primary source verification (PSV) of all credentialing elements and validates the information to ensure accuracy.
• Data entry of new applications in the credentialing database.
• Communicates clearly with providers, their credentialing representative, and leadership as needed to provide timely updates and responses on day-to-day credentialing and privileging issues as they arise.
• Analyzes, identifies, resolves discrepancies, time gaps, and other issues that could impact ability to credential healthcare practitioners.
• Report issues in a timely manner to Credentialing Manager for decision making in accordance with credentialing and privileging policy and federal state, local, and government and health plans standards.
• Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
• Process provider demographic changes ensuring appropriate documentation has been submitted with the changes, update credentialing database and notify health plans of changes.
• Prepare and scan credentialing/re-credentialing files and other credentialing documentation into electronic folder.
• Maintain knowledge of current requirements for credentialing providers.
• Ensure all tasks duties comply with all regulatory and accreditation standards including The Joint Commission, the National Committee Quality Assurance (NCQA) guidelines, and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
• Responsible for monitoring and managing credentials/recredentialing requirement to ensure the collection of all required renewals are on file within their required time frame.
• Responsible for the timely entry, processing, and tracking of credentialing files.

Other Job Responsibilities

• Ensure all actions, job performance, personal conduct and communications always represent CommUnityCare in a highly professional manner.
• Uphold and ensure compliance, confidentiality and adhere to all HIPAA guidelines, and maintain a strict level of confidentiality for all company policies and procedures, departmental, and healthcare provider information as well as the overall mission and values of the organization.
• Ensure that all work is done in a timely and accurate manner.
• Works within established credentialing timeframes and notifies manager as to status and barriers preventing work being done in a timely and accurate manner.
• Maintain strong working relationships with providers, health plan staff, and other credentialing verification offices.
• Develop and maintain favorable internal relationships, partnerships with co-workers.
• Responsible for the monthly ongoing monitoring of licenses and sanctions.
• Audit disciplinary reports, OIG reports, and other reports as required and initiate the formal complaint procedure, when applicable.
• Participates in staff meetings and recommends new approaches, policies and procedures to effect continual improvement in efficiency of the department and services performed.
• Respond to emails timely and effectively.
• Provide support to physicians, physician office staff, and company departments as necessary.
• Assist with annual Health Plan delegated credentialing audits.
• Cross train within department to support credentialing operations (back-up support for credentialing files, vacation/PTO).
• Participate in various educational/training as required.
• Perform other job-related duties as assigned.

Knowledge/Skills/Abilities:

• Articulates knowledge and understanding of organizational policies, procedures, and systems.
• Ability to function effectively and work under pressure in a demanding and fast paced environment.
• Ability to manage change, delays, or unexpected events appropriately, and demonstrate sense of urgency and strong time management awareness.
• Strong organizational, problem solving, and critical thinking skills, and to proactively prioritizes needs and effectively manages resources.
• Excellent interpersonal and customer service skills.
• Information research skills.
• Ability to communicate effectively both orally and in writing.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to function effectively in a remote work environment.
• Ability to work in both individual or group environment and multitask as needed.
• Demonstrate proficiency in Microsoft Word, Excel and Access.
• Knowledge of CAQH (Council for Affordable Quality Healthcare) database and application process.
• Knowledge of Medicare and Medicaid provider enrollment systems.

Qualifications

MINIMUM EDUCATION: High School Diploma MINIMUM EXPERIENCE: 2 years of experience in practitioner credentialing with a working knowledge of federal and state regulatory agencies and accrediting bodies (CMS, TJC, NCQA, etc.) REQUIRED CERTIFICATIONS/LICENSURE: Certified Professional Credentialing Specialist (CPCS) within first 3 years of employment if not already certified upon hire.