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Incumbent completes auditing of completed Provider, Facility and Ancillary credentialing and recredentialing cases, report results and assist with preparing training documentation for staff as required. Position also facilitates Credentialing Meetings for multiple states and works closely with all Medical Directors and Physician Members.
Review applications and supporting documents in a virtual environment and apply policy and criteria for credentialing processing.
May perform additional required primary source verifications.
Conduct outreach to providers, licensure bodies, attorneys and governmental agencies via phone, fax or written correspondence regarding high profile cases.
Maintain and update credentialing database and core system records.
Perform quality audits on completed credentialing and re-credentialing cases and maintain track/trend and training records of all audits conducted.
Educates staff on compliance, regulatory and accreditation requirements and responsibilities.
Prepare all issue cases for Medical Director and Credentialing Committee Review. This requires the ability to review legal documents, Board Orders, medical records and malpractice case descriptions and adequately summarize content for physician review.
Facilitate all assigned Credentialing Committee Meetings with ability to present material and lead discussions with groups of physician's and Senior personnel.
Create and maintain reports. Create presentation material and scribe official Credentialing Committee Minutes.
Provide support to credentialing associates and assist with handling complex questions and case reviews.
Demonstrate knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.).
Perform other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Required 3 years of experience in credentialing in a hospital or related managed care setting
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Ability to work as part of a team
Advanced Other Strong knowledge of process documentation and governing requirements
Intermediate Other Knowledge of credentialing software sufficient to develop appropriate reports on all aspects of credentialing
Licenses and Certifications: A license in one of the following is required: