Credentialing Program Manager

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Job Description

Summary:

The Credentialing Program Manager reports to the Medical Affairs Manager and/or Director. The primary purpose of the position is to direct, monitor and provide quality credentialing/privileging and re-credentialing/privileging processes to ensure that physicians and allied health practitioners meet applicable accrediting, legal, and regulatory standards. This Credentialing Program Manager identifies and assesses areas of compliance according to TJC, ODH, CMS and other accreditation agencies.

The Credentialing Program Manager serves as the content expert as it pertains to the credentialing process and responds to any inquiries regarding the credentialing/re-credentialing process from providers, hospitals, outside agencies/institutions, and other entities. In addition to medical providers, this individual interacts with medical staff office(s), quality management, compliance, medical staff and hospital leadership, and other professionals as necessary to ensure the integrity of the credentialing process.

The Credentialing Program Manager is responsible for a systematic, disciplined approach to ensure provider data accuracy and integrity, and independently investigates and validates information to report trends. Leads process improvement activities to ensure operating efficiencies of the credentialing process. This Credentialing Program Manager works directly with medical staff leadership regarding discrepancies identified in provider applications and may act as a liaison to state medical licensure boards.

The Credentialing Program Manager works independently under general supervision with considerable latitude for initiative and independent judgement.

Responsibilities And Duties:

70% Credentialing - Core Functions of the Credentialing Program Manager:

Conduct, participates in, and maintains credentialing and privileging.

Completes evaluation of a credentialing application to determine applicant’s initial eligibility for privileges. Analyzes application and supporting documents for completeness.

Verifies and documents expirable using acceptable verification sources to ensure compliance with accreditation and regulatory standards.

Performs detailed and thorough review of applications, primary source verifications, and sources provided.

Independently investigates and validates the information and escalates findings as needed.

Recognizes potential discrepancies and adverse information, and independently investigates and validates information in applications, primary source verifications, or other sources.

Determines the applicant’s initial eligibility for privileges based on approved criteria.

Compiles, evaluates and presents the practitioner-specific data collected for review by one or more decision-making bodies.

Serves as the main point of contact for the practitioner during the application process, providing timely updates and additional information as requested.

Manages the credentialing, recredentialing and privileging process.

Uniformly applies clearly defined credentialing/privileging processes to all practitioners.

Evaluates credentialing/privileging requests and evidence of education, training, and experience to determine eligibility for requested privileges.

Complies with internal and external requirements related to verifying the status of all practitioner expirables (e.g. licenses, certifications) by querying approved sources and recommending actions to ensure compliance.

Completes quality review of all completed appointment/reappointment files which includes, file audit check list completion, all supporting documentation, all query requirements, and file organization.

Facilitates the review of Physician and Allied Health Practitioner credentialing files. Is an active participant on Physician Credentials Committee…