Credentialing Specialist Managed Care

Credentialing Specialist Managed Care

Assists with managed care delegated credentialing audits and conducts internal file audits. Utilizes the credentialing database to optimize efficiency, performs query, report, and document generation, and submits and retrieves National Practitioner Database reports in accordance with the Health Care Quality Improvement Act. Monitors the initial, reappointment, and expirables process for all AHS-employed physicians, allied health professional staff, other health professional staff, delegated and community CIN providers affiliated with AHS. Ensures compliance with regulatory bodies as well as medical staff bylaws, rules and regulations, policies and procedures, and delegated contracts. Achieves productivity standards as determined by management. Other duties as assigned. Coordinates and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility. Conducts thorough background investigation, research, and primary source verification of all components of the application file, ensuring provider files are current and noted in detail in the system of record. Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow-up. Prepares credentials file for completion and presentation to the Adventist Health Systems (AHS) Delegated Credentialing Committee (DCC) or other affiliated credentialing committees within AHS, including Clinically Integrated Network (CIN) committees, ensuring file completion within specified time periods. Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions. 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.

Schedule/Shift: Fully Remote 8am-5pm est

Knowledge, Skills, and Abilities:

• Attentive to detail and accuracy; strong organization skills required.
• Ability to communicate effectively, both orally and in writing.
• Program planning and implementation skills.
• Knowledge of related accreditation and certification requirements.
• Knowledge of medical credentialing and privileging procedures and standards.
• Ability to analyze, interpret and draw inferences from research findings, and prepare reports.
• Working knowledge of clinical and/or hospital operations and procedures.
• Informational research skills.
• Ability to use independent judgment to manage and impart confidential information.
• Database management skills including querying, reporting, and document generation.
• Ability to make administrative/procedural decisions and judgments.
• Proficiency in Microsoft Office (Excel, Word, Outlook) and web-based applications.
• Excellent organizational, planning, and time management skills.
• High-level interpersonal skills, able to work collaboratively with multi-disciplinary and diverse teams.
• Ability to work independently, prioritize projects, and handle multiple projects and deadlines.
• Excellent problem-solving skills and ability to cope with interruptions.
• Knowledge of the Joint Commission standards and NCQA guidelines.
• Ability to work in a matrix-management environment to achieve organizational goals.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint).
• MSOW/Apogee.
• Medical Terminology.
• Understanding of credentialing principles and regulatory standards.
• Typing 35 wpm.

Education:

• Associate [Preferred]
• High School Grad or Equiv [Required]

Field of Study: in Healthcare Administration, Business or a related field

Work Experience: 1+ administrative support in a healthcare setting [Required]

Additional Information: N/A

Licenses and Certifications:

• Certified Professional Medical Staff Management (CPMSM) [Preferred]
• Certified Provider Credentialing Specialist (CPCS) [Preferred]

Physical Requirements: (Please click the link below to view work requirements) Physical Requirements

Pay Range: $19.76 $36.75

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.