Credentialing Specialist

Job Summary And Responsibilities

As a Credentialing Professional, you will be responsible for coordinating the credentialing, re-credentialing, and payer enrollment process for providers in accordance with delegated credentialing agreements, policies and procedures, industry best practices, and regulatory requirements.

Every day you will manage daily credentialing operations, including resolution of non-responsive providers. You will also work collaboratively with various clinic managers and the hospital medical staff office to ensure the successful and timely completion of the delegated credentialing and re-credentialing process.

To be successful in this role, you will demonstrate a comprehensive understanding of credentialing regulations and processes, possess strong organizational and communication skills, and effectively manage complex administrative tasks to ensure provider compliance and efficient operational flow.

Performs credentialing and re-credentialing processes according to departmental policies and procedures, various accreditation standards, health plan, state and Federal requirements.

Receives and reviews submitted applications for completeness and compliance with instructions for preparation; ensures the timely completion of applications by communicating with and assisting the applicants in submitting all documentation necessary to process the application; identifies deficiencies and follows up to gather missing or incomplete data.

Verifies all information (i.e., education/experience, training, qualifications, current/past affiliations, licensure, etc.) contained in the credentialing application to ensure that it is timely and accurate; requests and obtains documentation from a variety of sources (i.e., licensing agencies, educational institutions, insurance carriers, previous employers, etc.) in accordance with established procedures; obtains information regarding complaints and/or medical malpractice claims history; follows up as necessary to gather clarifying data;

identifies problematic information and refers to higher level authority.

Uses discretion and independent judgment in determining the need for deviation from standard processes or more detailed investigation, including those involving fees, or that would cause processing delays in order to clarify, verify and/or confirm information contained in the credentialing application.

Provides assistance and guidance to physicians and professional providers through the hospital privileging processes.

Meets with new providers (in person, electronically and/or by telephone) to explain the credentialing requirements, processes and timelines.

Identifies and resolves problems to support departmental objectives.

May coordinate hospital reappointments between hospitals and providers.

Prepares files, letters and summaries for Medical Staff Office and or Franciscan Medical Group (FMG) Credentialing Committee review.

Produces verification letters and prepares files containing all required supporting documentation; sends completed application files to Medical Staff Office for review.

Performs required follow up and/or monitoring as a result of Committee decisions.

Maintains all written/verbal correspondence and data collection records regarding provider status and credentialing process.

Keeps accurate and efficient records of all correspondence with providers, federal, state and local agencies, hospitals, medical review boards and malpractice carriers regarding provider status.

Ensures accurate and timely data entry of provider demographics.

Stores and retrieves non-electronic credentialing files.

Assists with productivity reporting.

Assists in preparation for health plan delegation oversight audits.

• Two (2) years practitioner credentialing experience or
• three (3) years administrative experience, that demonstrates attainment of the requisite job knowledge skills/abilities

• three (3) years administrative experience, that demonstrates attainment of the requisite job knowledge skills/abilities, preferably in a healthcare setting
• Certified Provider Credentialing Specialist, (CPSCS) upon hire

Virginia Mason Franciscan Health…