Senior Credentialing Specialist

Position Title: Senior Credentialing Specialist
Shift: Days
Schedule: M-F 8:00am-4:30pm
Compensation: $61,000-$80,000.00 annually
The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and comparisons to colleagues in similar roles

About Us
Saint Anthony Hospital is a diverse and community-centric hospital, your career can thrive in, while addressing the health and wellness challenges that families in our neighborhood face. Our employees deliver on our mission and achieve success by working together to provide excellent customer service and patient care.

As part of Saint Anthony Hospital's commitment to providing the highest quality health care, we will be building a new state-of-the-art hospital to serve as an anchor to the Focal Point Community Campus. Learn more at focalpointchicago.org.

Position Purpose: The Senior Credentialing Specialist is responsible for the coordination and administrative oversight of duties required for Saint Anthony PHO (PHO) participating provider credentialing and enrollment with managed care organizations (MCO) and provider organizations that are under contract through Saint Anthony PHO. Ensures the integrity of credentialing data and provides expertise and guidance to other credentialing associates.

Interacts extensively with physicians, MCO representatives, Saint Anthony medical staff services and clinical departments to facilitate physician enrollment and to maximize reimbursement for services rendered.

Facilitates the flow of information between medical staff departments, Saint Anthony PHO and Saint Anthony Hospital Administration.

This position exhibits knowledge of and follows the philosophy, mission, and vision of Saint Anthony Hospital. The incumbent demonstrates behavior consistent with the organization's core values and standards of service.

Essential Functions


1. Complete and accurately submit provider MCO enrollment applications, spreadsheets, and letters to contracted MCOs

2. Follow up with MCOs to ensure timely enrollment and participation of PHO providers, investigates credentialing denials and makes appropriate recommendations to correct

3. Complete online the CAQH ProView application and quarterly re-attestation for SAHA employed providers in a timely manner

4. Resource for and aid providers and their office staff for completing MCO initial credentialing and re-credentialing documents

5. Accurate data entry of all provider information and MCO participation status into the Credentialing Database

6. Attend hospital Medical Staff Onboarding Meeting and provide timely updates regarding provider contracting status with the PHO and credentialing status with contracted MCOs

7. Prepares and generates the monthly MCO Credentialing Status Report for Saint Anthony leadership and PHO Executive Committee Meeting that details at a minimum; par status by provider and MCO, CAQH attestation deadlines, credentialing application submission and acceptance dates, and missing credentialing information by provider.

8. Prepare and generate a monthly report for the contracted medical billing company regarding the billing/credentialing status of employed physicians

9. Notify contracted referral provider groups and management entity managing PHO risk-based contracts of PHO provider changes within the contracted timeframe that include; adds, demographic changes and terminations

10. Prepare and send the Saint Anthony PHO Membership packet to providers who have expressed an interest in becoming a participating provider and maintains a record of all returned provider agreements

11. Prepare and send out "PHO Welcome Letter" and executed participation agreement to new PHO providers

12. Maintains knowledge of current MCO and regulatory requirements for credentialing providers; including but not limited to the National Committee for Quality Assurance (NCQA)

13. Guides and answers questions from credentialing specialist and assists with questions and interdepartmental issues to help coordinate problem solving in an efficient and timely manner

14. Has the ability to prioritize work projects outside of day-to-day work tasks independently with minimum supervision.

15. Utilizes effective organizational skills to track requests and provide effective follow up on outstanding items in a timely manner

16. Consistently meets deadlines

17. Other responsibilities as assigned

Ø Performs both essential and marginal job functions in a safe manner as identified by Saint Anthony Hospital while adhering to the Hospital's confidentiality norms and standards. Actively and consistently demonstrates the core values of Saint Anthony Hospital in all interactions with others

Ø Assumes responsibility for knowing and maintaining established hospital and departmental objectives, policies/procedures including general sanitation, safety, environmental and infection control standards.

Ø Participates in performance activities including problem identification, data collection, solution selection, implementation and evaluation. Also assists in the care and maintenance of departmental equipment and supplies as appropriate.

Ø Participates in staff meetings and other in-services, meetings or committees as required.

General Job Requirements (List any required knowledge, skills, experiences or training, including length of time necessary for proficiency required to perform the job.)
• Associates Degree, (Bachelor's degree preferred)
• Minimum of five (5) years of recent credentialing experience within a PHO, IPA, or insurance carrier
• Experience in a production or administrative role requiring self-direction and critical thinking
• Extensive experience using a computer - specifically internet research, Microsoft Outlook, Word, Excel and Access, and other software systems
• Experience with advanced written and verbal communication
• Required knowledge of CMS, NCQA and other credentialing regulations.
• Maintains a high level of confidentiality for provider information
• Must be available to work late if necessary at the request of management
• Certified Provider Credentialing Specialist (CPCS) or participation in a CPCS progression program a plus