Job Details

Responsible for all aspects of credentialing for providers, to include but not limited to coordinating delegated and non-delegated credentialing activities, collecting credentialing information from providers, performing necessary queries and background checks on physicians, developing and maintaining credentialing files, performing credentialing activities necessary to maintain accreditation, and coordinating with insurance companies and third party payers concerning credentialing.

Duties:

• Initiates and processes provider applications for new providers for the purpose of credentialing and re-credentialing. Performs inquiries from the National Practitioner Data Bank, State Medical Board and other entities for the credentialing process.
• Develops an understanding of National Committee for Quality Assurance (NCQA) and Accreditation Association for Ambulatory Health Care (AAAHC) credentialing standards, Medicare and Medicaid credentialing regulations, and commercial insurance credentialing requirements. Participates in accreditation activities and development of credentialing policies and procedures.
• Develops an understanding of the credentialing processes used by each of provider services contracts and assists with expediting the process. May coordinate third party credentialing site visits as necessary. Coordinates third party credentialing delegation contracting processes.
• Provides credentialing information to IT department, electronic billing vendors, and any other parties to ensure claims can be sent by the IDX information system.
• Establishes and maintains effective lines of communication with each provider, departments, and clinics. Provides credentialing information to the billing offices and medical departments in the submission and resubmissions of claims.
• Maintains current files for all providers. Ensures provider files meet NCQA and delegated provider requirements.
• Maintains a central database showing the current credentialing status for each provider for all provider services contracts.
• Participates in medical group committees and teams. May assist with coordinating the Credentialing Committee and Credentialing Liaison Committee meetings.
• Performs various duties as needed to successfully fulfill the function of the position.