Responsible for coordinating the centralized provider application process for all product lines. Creates and maintains provider applications and tracks files through the re/credentialing process. Analyzes processes and solves problems to assure completion of the credentialing and recredentialing according to established standards and timelines.
RESPONSIBILITIES:
Log and track the provider applications and re/credentialing processes.
Duties include the following:
· Performs primary source verification and gathers appropriate information to complete credentialing and recredentialing within required timelines.
· Analyze the re/credentialing status of plan providers to assess re/credentialing timelines, and send recredentialing applications according to established schedules.
· Monitor receipt, as well as follow up until all documents are received and complete.
2. Enter application data and re/credentialing information into the credentialing database. Monitor the database on an ongoing basis to maintain integrity of data and identify and resolve data issues contained therein.
3. Interface with internal and external customers, providers and outside sources, such as the National Practitioner Data Bank and licensing boards, to ensure appropriate information in maintained and updated.
4. Create systems to monitor and track status of applications and maintenance of re/credentialing files, monitor primary source verification documents.
5. Conduct file comparison to established criteria and resolve problems on an ongoing basis to ensure re/credentialing file compliance with company policy and State and CMS standards.
6. Analyze progress of files through the credentialing and recredentialing process and provide ongoing and retrospective reports to Network Management and others as applicable.
7. Notify network management when a credentialing file is complete, and assure all information is forwarded to all users of information in a timely manner.
8. Conduct assessments of the organization provider database. Maintain, log, monitor and communicate status of re/credentialing files of organization providers to Network.
9. Communicates with Providers via verbal or written provider regarding application/reapplication discrepancies, and other credentialing issues.
10. Other projects as needed.
KNOWLEDGE, SKILLS AND ABILITIES
Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff. Coordinator (CMSC) or equivalent experience (3 yrs +) preferred.
Minimum 2 years credentialing experience and knowledge of medical terminology.
High School Graduate or some College.
Database management and computer knowledge/experience required.
Analytical and problem solving skills.
