CREDENTIALING SPEC

Overview

Credentialing Specialist, Business Office

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is East Tennessee’s top-performing healthcare network with 10 hospitals and over 85 outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned, not-for-profit healthcare system and the area’s largest employer with over 11,000 employees.

Covenant Health is the only healthcare system in East Tennessee to be named six times by Forbes as a Best Employer

Position Summary: This position is responsible for prioritizing and managing tasks in the Managed Care department in regards to Payer Enrollment and Hospital credentialing. With limited supervision, the Credentialing Specialist acts as a liaison among Covenant Medical Group (CMG) office managers, Medical Staff coordinators, and hospital administration. The specialist may do any of the following: process payer enrollment, facility credentialing, pro-fee enrollment, expirables, hospital credentialing / re-credentialing applications for CMG Providers, Medical Staff members and advanced practice professionals, and maintains credentialing database.  Enrolls new CMG and Pro-fee providers with Payers; send out and process initial hospital applications; performs verification of payer enrollment and reappointment applications by preparing requests for information; tracks responses and follow up on requested information.   Assists the Manager, System CVO Operations as requested, and attends meetings as needed. Specialists will be expected to cross-train in all above areas for department efficiency.

Recruiter: Kathleen Rice || kkarnes@covhlth.com || 865-368-7313

Responsibilities

• Process either new CMG payer enrollment, Pro-fee enrollment, facility credentialing, hospital credentialing or re-credentialing applications of physicians and advanced practice professionals, including the review of applications and other data for accuracy and completeness; preparation and distribution of correspondence such as requests for information; verification letters; verification of licensure/certifications; background checks.
• Accurately enters required hospital credentialing data into the Visual Cactus credentialing database, and payer enrollment data into CAQH.
• Follow-up on CMG Payer enrollment, track/verify hospital reappointment for accuracy, demographic changes, practice changes, and coverage arrangement.  
• Verify initial and re-verify for reappointment; medical/dental licensure, federal DEA registration, board certification, and malpractice insurance coverage.
• Expirables: Track and update monthly TN State License, DEA, and Board Certifications for all physicians and advanced practice professions in Visual Cactus.
• Assure timely processing of new hospital credentialing applications for assigned facilities, payer enrollment, pro-fee, and facility credentialing. Maintain provider credential files in a neat, accurate, and organized manner.
• Handle all payer enrollment and credentialing information in a strictly confidential manner.
• Meet physician, MSO, and clinic requests, be able to respond to questions regarding general information of payer enrollment, hospital credentialing, pro-fee credentialing.
• Perform all other related duties and responsibilities as assigned.

Qualifications

Minimum Education: 

None specified; will accept any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to an Associate’s degree.  

Minimum Experience: 

Minimum of two (2) years’ experience in Payer enrollment or hospital credentialing; knowledgeable with Joint Commission and NCQA credentialing standards; experience with Visual Cactus preferred;  good organizational, data entry,  and communication skills.

Licensure Requirement: 

None