Lead Credentialing Specialist - Full-Time - Atlantic Health

Lead Credentialing Specialist

The role will be based at Atlantic Health Overlook Medical Center in Summit NJ with travel expectations for other sites.

Purpose:

Participates in complex departmental activities to ensure quality in conducting, maintaining, and communicating the medical and allied health professional staff credentialing, privileging, and primary source verification process. Audits, measures performance, trains team, serves as a resource of the department, and collaborates with management to advance the quality of practitioners and patient safety of the facility. Assists with additional duties including coordination and review of department activities.

Essential Functions:

30%:

• Audits, analyzes, and monitors credentialing application/files processed by Credentialing Specialist staff to ensure appointments are processed in required timeframes, including all required primary source verifications and accompanying documentation, to ensure files meet regulatory requirements.

20%:

• Documents and tracks performance statistics of the Credentialing Specialists application processing related to accuracy and communicates with the managers when issues are identified.
• Reviews statistics regarding performance measures and goals with management regularly and assists with identifying trends.
• Trains new and existing staff on how to process initial and/or reappointment/re-credentialing applications.

15%:

• Determines practitioner eligibility for membership/participation or changes in status.
• Analyzes application and supporting documents for accuracy and completeness and informs the practitioner of the application status, including the need for any additional information or corrections.
• Obtains, researches, and evaluates information from primary sources to ensure compliance with accreditation and regulatory standards to validate accuracy of applications for one or more decision making bodies, including a thorough background investigation and primary source verification of all components of the application file, such as applicant's education and training, licensure, work history, hospital affiliation history, malpractice claims history, board certification status, criminal background, evaluation of health status, and peer recommendations.
• Recognizes, investigates, and validates discrepancies and adverse information obtained during the application process to ensure review and approval bodies have information needed to make informed credentialing decisions.

15%:

• Reviews file for accuracy and completeness before submission.
• Routes the credentials files to the department chief/chair or designee for review and recommendation for membership and privileges.
• Coordinates expedited credentials committee and board approval process for credentials files being recommended by the departments.
• Coordinates emergency privilege requests for hospital privileges as needed.
• Prepares practitioners credentials files for presentation to the Atlantic Health's hospitals Committees and Board.

15%:

• Assists the Credentialing Specialists with the National Practitioner Data Bank Continuous Query Renewals.
• Responds to inquiries from other healthcare organizations and interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
• Communicates the status of applicant files directly to providers and various department representatives, clients, and/or affiliates and coordinates efforts to obtain necessary information and/or documentation to ensure deadlines are met.
• Assists management with review and assessment of departmental functions and services to identify areas in need of review or improvement and implement changes as needed.
• Assists with various aspects of the credentialing expirables process, including but not limited to, the ongoing monitoring of sanctions, board certification status, and current malpractice coverage. Represents the Medical Staff Services Department for various initiatives, audits, and/or committee meetings as needed. Serves as the primary back up to all credentialing staff including the Credentialing Coordinator. Serves as a Team Peer Interviewer as needed.

5%:

• Other duties as assigned.

Qualifications

Education:

• Associates' degree in Business or Healthcare Administration or related field AND 3 years of experience in Medical Staff credentialing and/or payer enrollment functions required OR equivalent combination of education and experience.

Experience:

• Proficiency with credentialing software systems to manage provider data, workflows, and documentation accurately and securely.
• This includes strong data entry and reporting skills, electronic document management, knowledge of compliance and HIPAA requirements, and proficiency with Microsoft Office tools.
• Experience troubleshooting system issues, adapting to software updates, and following electronic workflows and audit requirements is also preferred.

Knowledge, Skills and Abilities:

• Fluent English language skills (verbal and written)
• Knowledge of and experience with Joint Commission, CMS, and NCQA Regulations related to medical staff services and Commercial Payers Credentialing
• Exceptional interpersonal and communication skills
• Ability to develop and maintain relationships with a variety of key stakeholders across the organization

Licenses/Certifications (Preferred):

• Certified Medical Professional Services Management (CPMSM)
• Certified Provider Credentialing Specialist (CPCS)