Credentialing Specialist I - Professional Staff

GENERAL SUMMARY

The Credentialing Specialist I reports to the Director of Professional Staff and is responsible for supporting departmental activities to ensure quality in conducting, maintaining, and communicating physician credentialing, privileging, and primary source verifications, as well as ensuring compliance with Bylaws, Rules and Regulations, State and Federal requirements, and accreditation standards.

Serves as a resource to, and collaborates with, others to advance the quality of practitioners and patient safety of the facility.

This individual may also be mentored by any Credentialing Specialist II within the department.

Actively seeks to promote and maintain, through interactions with others within and outside the department, a positive, professional, team-oriented, and service-conscious environment that contributes to the goals of the department and reflects the values and mission of CHKDHS.

ESSENTIAL DUTIES AND RESPONSIBILITIES

CONDUCTS, PARTICIPATES IN, AND MAINTAINS PRIMARY SOURCE VERIFICATION

Perform outreach to primary sources for practitioners' information.

Obtain and evaluate information from primary sources.

Perform detailed and thorough review of applications, primary source verifications, and sources provided.

Recognize potential discrepancies and adverse information, and independently investigate and validate information applications, primary source verifications, or other sources.

Verify and document expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards.

Serve as main point of contact for external queries regarding practitioners' status, providing responses in a timely matter.

CONDUCTS, PARTICIPATES IN, AND MAINTAINS CREDENTIALING AND PRIVILEGING

Complete evaluation of application to determine applicant's initial eligibility for membership / participation, based on approved criteria.

Review application and supporting documents for completeness.

Uniformly apply clearly defined credentialing or privileging processes to all providers.

Evaluate credentialing / privileging requests and evidence of education, training, and experience to determine eligibility for requested privileges, membership, and / or plan participation.

Serve as main point of contact for practitioner during application process, providing timely updates and additional information as requested.

Compile, evaluate, and present the practitioner-specific data collected for review by one or more decision-making bodies.

Perform initial or reappointment / re-credentialing for eligible practitioners.

Process requests for privileges.

Conduct, participate in, and maintain credentialing verification organization (CVO).

CONDUCTS, PARTICIPATES IN, AND MAINTAINS CURRENT CLINICAL COMPETENCY EVALUATIONS AND PEER REVIEW

Obtain and assess information from various referral sources.

Recognize, investigate, and validate discrepancies and adverse information obtained.

Communicate findings and / or resulting actions to supervisor and department peers (CS II).

COMPLIES WITH ACCREDITATION AND REGULATORY STANDARDS

Compile practitioner sanctions, complaints, and adverse data to ensure compliance.

Demonstrate an understanding of state and regulatory standards.

Demonstrate an understanding of state and regulatory standards in relation to telehealth and credentialing by proxy.

MANAGES COMPLIANCE WITH STATE AND FEDERAL ACCREDITATION STANDARDS AND REGULATORY REQUIREMENTS

Facilitate efficient and cost-effective due process that complies with an organization's fair hearing and appeals policy as well as applicable legal and regulatory requirements.

Identify and report to their supervisor adverse actions taken against a practitioner / provider in accordance with applicable law and contractual requirements.

Monitor and / or report sanctions and complaints for all practitioners / providers to supervisor.

Develop informational / educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies.

Develop and cultivate working relationships with key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making.

MANAGES DEPARTMENTAL OPERATIONS

Maintain credentialing database continuously and consistently to ensure that accurate and current information is available to all stakeholders.

Audit, assess, procure, implement, effectively utilize and maintain practitioner / provider credentialing processes and information systems (e.g., files, reports, minutes, databases) as outlined by the department.

FACILITATES MEDICAL STAFF FUNCTIONS

Manage and maintain compliance records of periodic and / or annual provider requirements such as vaccinations, annual education, etc.

Facilitate and attend, as assigned, committee, general staff and department meetings.

Secure meeting rooms, arrange for catering and special equipment needs for above meetings.

Prepare minutes of meetings for dissemination to members and others among senior leadership.

Record conclusions and recommendations accurately to substantiate actions taken by departments or committees.

Maintain and protect the confidential records of proceedings which may be required in subsequent internal investigations and / or legal disputes.

ANALYZES AND MANAGES DATA

Securely manage information as the single source of truth by effectively navigating database software and maintaining data integrity.

Use database software for training, reporting, as well as integrating with other IT and revenue systems.

LICENSES AND / OR CERTIFICATIONS

CPCS and / or CPMSM certification by the National Association Medical Staff Services (NAMSS) preferred.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

High school diploma or equivalent required.

College degree preferred.

At least 3 years previous hospital credentialing experience preferred.

Proficiency in credentialing software required, MD-Staff preferred.

Proficiency in Microsoft Office products required.

Working knowledge of DNV and CMS accreditation standards related to credentialing required.

Basic statistical knowledge and experience required.

Analytical, problem-solving, organizational and prioritizing skills required.

Strong oral, written and interpersonal communication skills required.

Effective meeting management skills required.

WORKING CONDITIONS

Fast-paced, extremely busy office environment where interruptions are frequent.

Works in a normal office environment with little exposure to excessive noise, dust, temperature and the like.

PHYSICAL REQUIREMENTS

Click here to view physical requirements.

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