Credentialing Specialist

Description

POSITION SUMMARY

Obtains all primary source information necessary for all organizational facilities and entities. The incumbent maintains records and the integrity of highly confidential information that is protected from discovery by applicable state statutes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to the following:

• Performs the appropriate credentialing processes in a timely and complete manner for providers billing under PVHO Tax ID
• Performs analysis and appropriate follow-up. Works with many individuals to acquire necessary materials and information, including, but not limited to: physicians, Advance Practice Providers, facility staff and professional staff
• Performs relevant data entry into the database to ensure consistency and integrity of the data
• Processes appropriate queries for expired licensure, or any appropriate regulatory credentialing requirement and maintains documentation in the database.
• Compiles and maintains documentation in database
• Completes provider credentialing and recredentialing applications; monitors applications and follows up as needed
• Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all PVHO providers and its divisions providing medical services and processing claims under PVHO’s tax ID only.
• Maintains knowledge of current health plan and agency requirements for credentialing providers
• Tracks license, DEA and professional liability expirations
• Maintains appointment files and information in credentialing database
• Audits health plan directories for current and accurate provider information

Requirements

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)

Must possess a strong knowledge and understanding of healthcare planning as normally demonstrated through three years of credentialing and/or process management and operations experience. Requires a basic knowledge of medical terminology, medical staff organization and extensive knowledge of

credentialing procedures. Must have experience in interacting with physicians and allied health professionals, their office credentialing representatives and hospital personnel.

Must have excellent communication skills, both verbal and written, along with astute judgement in areas of human relations. Must demonstrate an ability to meet deadlines in a multi-functional task environment. Requires excellent organizational skills and operational knowledge with work processing, spreadsheets, data entry, fax machines, and other computer related skills. Must, at all times, maintain efficiency and timeliness in all daily activities. Must be able to establish daily work priorities and work efficiently to contribute to the successful overall maintenance of the credentialing process. Provides optimal customer service to meet the organization’s expectations.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.

NOTE

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.