Credentialing Coordinator

Western Wayne Family Health Centers (WWFHC) is a nonprofit organization operating four Community Health Centers in Michigan, providing comprehensive services such as primary care, general dentistry, obstetrics, gynecology, behavioral health, and substance abuse treatment. Founded in 2006, WWFHC is a Federally Qualified Health Center recognized as a Patient-Centered Medical Home and Behavioral Health Innovator. Serving over 16,000 patients annually, the organization offers affordable care through a sliding fee scale and accepts a range of insurance plans, including Medicaid.

WWFHC is also an active teaching site for medical, dental, and nursing students, contributing to healthcare training and access across underserved communities.

Purpose:

The Credentialing Specialist is responsible for the processing of initial credentialing, privileging, re-credentialing and re-privileging applications of health care providers, as well as processing provider enrollment applications and supporting documentation for payer enrollment and re-enrollment. The position includes follow up on the status of applications and tracking progress on all pending applications. The Credentialing Specialist maintain the provider files and reports, which include provider demographics, correspondence with insurance plans, status of applications and pertinent licenses and certifications.

He/she has knowledge of commonly used credentialing concepts, practices and procedures to perform the functions of the job and must be detail oriented and thorough in order to ensure the complex enrollment packages are complete and correct. Communication with providers and others within the organization is essential.

• Workwith providers in person, by phone, fax, USmailor email to obtain provider credentialing and insurance enrollment forms and all supporting documentation.
• Maintain current andaccuratedata needed for the credentialing and re-credentialing process for all providers.
• Process applications for appointment and reappointment of privileges to WWFHC.
• Utilize the credentialing database andperformsquery,reportand document generation;submitsand retrieves National Practitioner Data Bank reportsin accordance with
  
  FTCA and HRSA requirements.
• Conduct thorough background investigation,research and primary and secondary source verification of all components of the application file per FTCA and HRSA requirements.
• Identify issues requiring additional investigation and evaluation; validate discrepancies and ensure appropriate follow up.
• Preparecredentialsfile for completion and presentation to WWFHC Medical Director and Credentials Committee.
• Maintain copies of current state licenses, DEA and board certificates, malpracticecoverageand any other required credentialing documents for all providers.
• Track licenses, DEA and board certificates, malpractice coverage expirations for appointed WWFHC providers.
• Respond to inquiries from other healthcare organizationsregardingcredentialing and privileging issues as they arise.
• Maintain Credentialing and Privileging data required by FTCA for Licensed Independent Providers and Other Licensed Providers at Western Wayne Family Health Centers for annual submission to FTCA.
• Work with credentialing specialists, contracting departments, networkmanagementand provider representatives at the insurance plans toassistina timelyenrollment process, providingadditionalinformation as required by the individual plan.
• Follow up with providers to ensure that all necessary information is received and that the enrollment process is completed timely.
• Perform follow-up with insurance plans to resolve provider enrollment issues and obtain provider participation status.
• Perform tracking and follow up to ensure provider enrollments are approved and linked to the appropriategroupentity and location in a timely manner.
• Maintain documentation and reportingregardingprovider enrollments inprocess.
• Maintain up-to-date insurance files with applications, acceptance letters, providernumbersand completed provider enrollments.
• Retain detailed andaccuratelists of insurance plans in which providersparticipateand their…