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SUMMARY: Responsible for providing credentialing support for the activities of the Medical Staff; coordinates credentialing, re-credentialing and provider enrollment including but not limited to the maintenance of accurate, up-to-date credentials files, initial appointments, reappointments and all other requests that are within the scope of the medical staff bylaws.DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.Responsible for the coordination of all aspects of the credentialing, privileging and enrollment processes for the Medical Staff including but not limited to the maintenance of accurate, up-to-date files.
Accountable for the utilization of any computer software program(s) necessary to support the credentialing process and maintaining the database including but not limited to data entry, scanning documents and maintaining data sufficient to pre-populate applications supported by the database.
Facilitates medical staff committee meetings including meeting reminders, agendas, minutes reflective of the discussions and actions taken and performs follow up.
Accountable for the completion of files to the Credentials Committee for recommendation of approval in accordance with the medical staff bylaws.
Works with payers to facilitate issue resolution, re-enrollment, and termination requirements.
Responsible for the management and oversight for the Focused Professional Practice Evaluation (proctoring) process for all initial appointments and any privilege modifications.
Collaborates with the quality department to implement principles of ongoing professional practice improvement and focused professional practice improvement are utilized within the medical staff.
Coordinates responses to inquiries regarding payer’s applications; follows up with each payer and or provider until enrollment is complete; assesses provider credentialing files to determine if additional information is required; revisits state and federal bulletins for provider sanctions.
Participates in surveys by regulatory bodies (TJC, NCQA, CMS, federal and state) and health plan audits.
Reviews and processes mail and/or interdepartmental correspondence as received.
Performs other duties as required.
MINIMUM QUALIFICATIONS:Required Education: Bachelor’s degree from an accredited college or university, or equivalent experience in related field.Required Experience: Two years combination of Medical Staff Services and/or Health Plan credentialing experience.Preferred Experience: Medical Staff credentialingRequired Licenses/Certifications: Certification from the National Association of Medical Staff Services as a Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS); if not certified at the time of hire, certification must be obtained within three years for CPSC and/or five years for CPMSM depending on experience and satisfying of National Association of Medical Staff Services educational requirements.
