Posted on February 2nd, 2021
This non-exempt position is responsible for all aspects of the credentialing and re-credentialing processes for all medical providers who provide patient care for Santé Physicians, IPA (SP). Responsible for ensuring providers are credentialed and all required documents are submitted to the contracted health plans. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.
Minimum four (4) years’ experience in a healthcare delivery environment or three (3) years in credentialing activities. High School diploma or equivalent required. AA/AS degree preferred. Knowledge and understanding of the credentialing process. Ability to research and analyze data and remain current with NCQA, State and Federal regulations related to health plan credentialing activities. Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred or expectation of securing certification within three years of hire date.
1. Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed.
2. Maintains copies of current state licenses and any other required credentialing documents for all providers as it pertains to our current SP Credentialing Policies and Procedures.
3. Tracks license and certification expirations for all providers to ensure timely renewals.
4. Submits quarterly and/or semi-annual credentialing/recrdentialing reports to requesting health plans.
5. Maintains knowledge of current health plan and agency requirements for credentialing providers.
6. Sets up and maintains provider information in online credentialing databases and system.
7. Responsible for the timely entry, processing and tracking of credentialing files.
8. Reviews credentialing files for accuracy and completeness. Performs primary source verification of practitioner credentials following National Committee for Quality Assurance (NCQA) and Centers for Medicare & Medicaid Services (CMS) accreditation guidelines.
9. Monitors and assists further investigations as deemed necessary during the credentialing process by document evaluation, primary source verifications or as requested from Credentials Committee and SP Chief Medical Officer.
10. Prepares initial credentialing and/or re-credentialing files for the monthly Credentials Committee.
11. Works closely with Provider Contracting to ensure the credentialing application process is efficient and meets established turnaround times.
12. Attends monthly Credentialing Committee meetings and act on the decisions of the committee regarding files processed.
13. Attends and participate in Credentialing department staff meetings.
14. Initiates provider file updates using the Apogee system as required.
15. Maintains confidential credentialing files and electronic credentialing database.
16. Participates in credentialing team quality audits.
17. Participates in the development and implementation of departmental policies, procedures, forms, etc.
18. Other duties as assigned
Ability to organize and prioritize work and manage multiple priorities. Excellent verbal and written communication skills including, letters, memos and emails. Ability to multi-task and deal with complex issues on a frequent basis.Excellent attention to detail. Ability to work independently with minimal supervision. Ability to maintain a professional demeanor and confidentiality.Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization. Proficient use of Microsoft Office applications (Word, Excel), internal databases and internet resources.
TYPICAL PHYSICAL DEMANDS
Requires prolonged sitting, some bending, stooping or stretching. Manual dexterity sufficient to operate a keyboard, photocopier, calculator, telephone and other office equipment as necessary. Requires normal range of hearing, eyesight and speech to prepare and communicate appropriate reports and to train staff in system applications.
Please send resumes to firstname.lastname@example.org