Position Purpose: Reporting to the Credentialing Supervisor, the Credentialing Coordinator facilitates the accurate and efficient Credentialing and Recredentialing of SHCN providers in alignment with State, Federal, and NCQA standards.
- Responsible for ensuring timely processing credentialing, recredentialing, practitioner files, organizational files and the credentialing database, and coordination of the Credentialing Committee meeting including meeting minutes for reporting to the Quality Improvement Committee as needed. Conduct internal and external validation of credentialing file audits, and address identified issues in a timely manner.
- Facilitate prompt coordination with the Credentialing Verification Organization (CVO) and monitor Work in Progress (WIP) file, promptly addressing incoming files for processing. Review and maintain all applications for accuracy and completeness, ensure primary source verification, and overall processing time frames are met. Generate forms, letters, checklists, and maintain the internal tracking data base/data entry, ensuring complete and accurate data entry.
- Contribute toward the coordination of the Credentialing Committee by accurate and complete preparation of credentialing and recredentialing files. Identify and communicate agenda items to the Credentialing Director to be addressed at the Credentialing Committee. Facilitate preparation of files for electronic storage. Assist in updating the database to reflect Credentialing Committee decisions.
- Coordinate with Network Services or other sources as necessary on follow-up items needed to complete the credentialing process. Communicate to Network (or other internal departments) regarding status of provider and organizational credentialing.
- Maintain on-going participation in cross-training activities. Actively engage in addressing special projects as they arise, conducting preliminary research and follow-up, and tracking/monitoring to facilitate on-going reporting of project status. Provide recommendations and feedback regarding development of process improvements and/or standardization practices. Other duties as assigned.
- Associates degree in a related field (or equivalent combination of education and experience).
Years of Experience:
- A minimum of two years of relevant experience in healthcare related environment, preferably within a credentialing/recredentialing environment and knowledge national accreditation or regulatory criteria.
Work Related Experience:
- Microsoft Office software (Word, Access, Excel, PowerPoint), and preferably experience with Credentialing systems.
- Previous Managed Care and/or Medicaid experience strongly preferred.
- Ability to analyze and evaluate data and other provider related problems in order to develop alternative solutions for a positive outcome.
- Ability to multi-task and prioritize workload, manage multiple priorities, and pay meticulous attention to detail.
- Thorough understanding of managed care principles and physician practice operations, with an understanding of health plan provider enrollment and credentialing preferred.
- Excellent organizational skills, proven project management expertise; Strong verbal and written communication skills.