Credentialing & Privileging Specialist

As a member of the Human Resources Team, the Credentialing & Privileging Specialist plays a critical role in developing and execution of proactive strategies to meet the credentialing and privileging needs for St. John’s Community Health (SJCH). The Credentialing & Privileging Specialist is responsible to process all SJCH clinic credentialing and re-credentialing applications and/or enrollments of health care providers. This position maintains a database, applications, prepares verification letters for licensing agencies, and works with Human Resources and the provider enrollment unit.

Benefits:

• Free Medical, Dental & Vision
• 13 Paid Holidays PTO
• 403 (B) retirement match
• Life Insurance, EAP
• Tuition Reimbursement
• Flexible Spending Account
• Continued workforce development & training
• Succession plans & growth within

Qualifications/Licensure: 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education & Experience           

• 5-7 years of experience with credentialing and privileging in a managed care, clinic, and/or non-profit healthcare organization.
•  A Bachelor’s degree in healthcare administration, public health, business, or a related field.
• Certified Provider Credentialing Specialist (CPCS), preferred.
• Experience with data queries and source verification of credentials and familiarity with the National Provider Data Bank.
• Exceptionally skilled with data entry and data management.
• Ability to communicate both in writing and orally with all levels of the organization in various modes of communication.
• Possesses an understanding of how credentialing impacts billing, contracts, and revenue generation.
• Ability to learn new database management systems and medical software programs.
• Ability to accurately complete detailed reports and forms.
• Ability to investigate and find solutions to problems and determine the best course of action.
• Ability to multitask, prioritize workflow and meet deadlines.
• Ability to work independently and as a member of various teams and committees.
• Acute attention to detail.
• Demonstrated ability to plan and organize projects.
• Able to work collaboratively with multiple health professionals in a busy and complex environment using tact, diplomacy, and discipline.

Responsibilities

Performs a combination, but not necessarily all, of the following duties:

• Accurately completes credentialing and privileging, and re-credentialing and re-privileging processes, including, but not limited to, forwarding applications for credentialing and/or clinical privileges to all qualified applicants, and securing primary and secondary source verification in accordance with HRSA.
• Ensures that credentialing and re-credentialing of providers occurs on a timely basis in accordance with industry and organizational standards.
• Coordinates privileging criteria for various providers/practitioner roles; reviews and assists with updating privileging criteria based on changes in industry standards, evidence-based practices, and regulatory requirements. 
• Identifies opportunities for process improvement and efficiency in the credentialing and privileging workflow; analyzes data and metrics to identify areas for improvement; and assists with the implementation of best practices and innovative solutions to enhance the overall effectiveness of the department and its processes.
• Monitors all delegation protocol forms for both mid-levels & supervising physicians.
• Oversees maintenance of well-organized provider files that are easily reviewed by SJCH’s Credentialing Committee, outside review bodies, and others. 
• Supports audits and provides the Department with the necessary information.
• Coordinates monthly Peer Review and quarterly Credentialing Committee meetings; sends members calendar invites and reminder emails; prepares agenda, credentialing and re-credentialing list, and cases for review and determination, takes minutes to present to board members for approval and disseminates for review.
• In-depth knowledge of governmental insurance eligibility and verification Medicare, Medi-Cal, HMO, PPO, and publicly funded programs Family PACT, CPSP, CPE, and grants.
• Analyzes provider membership assignments and trends to determine where variances are occurring and develop reports to assess these variances.
• Coordinates with the Operations department and schedulers regarding provider panels and provider-assigned locations to update provider credentialing files and the IPA.
• Notify Health Plans when a Provider relocates to a different medical home within St. John’s and/or resigns.
• Summarizes credentialing information, data, and recommendations, and prepares presentation materials. May present findings to management.
• Creates/develops regular and ad-hoc reports.
• Uses independent judgment to resolve issues and recommend solutions.
• Completes complex/special assignments.
• Supports with training and communication of pertinent information affecting the team and other stakeholders.
• Attends administrative meetings and participates in committees as requested; conducts special projects and studies as directed.
• Processes approval, denial, or termination letters.
• Enters and uploads providers’ dates onto ADP database.
• Maintains a credentialing tracking list for all LIPs (Physicians, Mid-levels), OLCPs and OCS.
• Upon fully credentialing Per Diem, coordinates with various departments EMR training, via email to the Development Department, IT, Billing Director and Chief Pharmacy Officer.
• Assists with Locum/Tenens in preparing contracts and negotiations.
• Receive CV from locum tenens, review and run NPDB prior to sending to Development Department for
• scheduling interviews.
• Works with CMO and/or MLT Leader in coordinating all CME hours and expense approvals.
• Collects all pertinent information from the provider, provider’s malpractice insurer, National Practitioner Data Bank (NPDB) and other sources.
• Maintains accurate and complete records of each application's status, including all credentialing and re-credentialing timelines and schedules.
• Leads and prepares the agenda for the credentialing review committee meeting and other meetings related to credentialing and privileging.
• Coordinates and confirms start dates for new providers communicating and updating when the provider is clear to start.
• Maintains a strict level of confidentiality on all matters and protects the confidentiality and security of credentialing and privileging information.
• Processes approval, denial, and termination letters.
• Tracks progress of outstanding applications, reports progress and maintains current copies of relevant credentials.
• Works effectively in team environment to coordinate all credentialing processes.
• Monitors and obtains documentation and follows up to ensure timely resolution of outstanding requests.
• Conducts quality assurance reviews on completed credentialing files.
• Monitors expiring applications, notifies the healthcare practitioner in advance of pending expiration dates for re-credentialing and re-privileging and resolves issues before expiration dates.
• Maintains well-organized healthcare practitioner files and supports audit processes.
• Manages the annual TB documentation and reminders to employees.
• Uploads credentialing and privileging documentation into employee’s profile on HRIS.
• Oversees the credentialing compliance database and serves as main point of contact with outside vendors and internal partners for credentialing- and privileging-related matters.

St. John’s Community Health is an Equal Employment Opportunity Employer