Medical Staff Credentialing Specialist

Medical Staff Credentialing Specialist

Responsible for all aspects of the credentialing, recredentialing, and privileging processes for all medical providers who provide patient care at Chesapeake Regional Healthcare and Ambulatory Surgery Center (ASC). Responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.

Duties and Responsibilities

• Maintain and apply knowledge of current credentialing principles and requirements for all Medical Staff, Independent Practitioner, and Allied Health Professional (AHP) practitioners as required by Medical Staff Bylaws, Medical Staff Rules and Regulations, accreditation organizations, and state/federal regulations
• Review and screen initial and reappointment credentialing applications for completeness, accuracy, and compliance with federal, state, and local regulations, guidelines, policies, and standards
• Conduct primary source verification; collect and validate documents to ensure accuracy of all credentialing elements; assess completeness of information and qualifications relative to credentialing standards and CRH criteria
• Identify, analyze, and resolve extraordinary information, discrepancies, time gaps, and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discover and convey problems to Credentialing Manager and entity Medical Staff Affairs for sound decision-making in accordance with Medical Staff Bylaws, credentialing policies and procedures, and federal, state, local, and government/insurance agency regulations
• Monitor files to ensure completeness and accuracy; review all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepare and provide information to internal and external customers as appropriate
• Enter, update, and maintain data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, in accordance with internal policies and procedures
• Prepare, issue, electronically track, and follow up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines
• Participate in the development and implementation of process improvements for the system-wide credentialing process; prepare reports and scoring required by regulatory and accrediting agencies, policies, and standards
• Communicate clearly with providers, their liaisons, entity Medical Staff Affairs, medical staff leadership, and Administration, as needed to provide timely responses on day-to-day credentialing and privileging issues
• Maintain professional growth and development through seminars, workshops, and professional affiliations to stay abreast of the latest developments and enhance understanding of healthcare regulations and legislation
• Perform miscellaneous job-related duties as assigned
• Manage students' clinical rotations
• Maintain a working knowledge of accreditation organization standards and other regulatory requirements related to credentialing
• Support committee meetings and prepare and disseminate Medical Staff committee assignment notices, annual dues notices, meeting fine notices, and attendance records
• Prepare and disseminate the monthly Emergency Department on-call schedule for various specialties
• Maintain the highest level of confidentiality regarding practitioner personal information and related peer review information
• Post Medical Staff information to the Intranet in a timely and accurate manner, including call schedules, calendars, department meeting schedules, committee listings, Executive Committee highlights, and special notices

Other

• Attend required hospital-wide orientations, meetings, patient safety fairs, in-services, as well as job-related conferences, audio conferences, and webinars
• Demonstrate a commitment to flexible work scheduling when necessary to ensure adequate departmental staffing and efficient operations
• Improve professional growth and job performance by participating in professional organizations such as Tidewater Association Medical Staff Services (TAMSS) and Virginia Association Medical Staff Services (VAMSS), and by reading pertinent journals and publications addressing current Medical Staff issues

Reporting Structure

• Reports to: Director, Medical Staff Services
• Supervises: None
• Responsibilities: Not applicable

Qualifications

Minimum Required Education: High school diploma with courses in business, data entry, and computer software

Preferred Education: Associate's degree or higher

Experience: One (1) to Two (2) years' experience in the Medical Staff Services department of an acute care hospital, ambulatory surgery center, or a managed care credentialing office to include experience with an electronic credentialing database application

Preferred certifications: National Association Medical Staff Services CPCS or CPMSM certifications