Credentialing Specialist I - Professional Staff
- Location Norfolk, VA
- Facility Children's Hospital of The King's Daughters - Main Hospital
- Department Professional Staff
- Schedule - Shift - Hours Full
-time - Days
The Credentialing Specialist I reports to the Director of Professional Staff and is responsible for supporting departmental activities to ensure quality in conducting, maintaining, and communicating physician credentialing, privileging, and primary source verifications, as well as ensure compliance with Bylaws and Rules and Regulations;
State and Federal requirements; and accreditation standards. Serves as a resource to, and collaborates with, others to advance the quality of practitioners and patient safety of the facility. This individual may also be mentored by any Credentialing Specialist II within the department. Actively seeks to promote and maintain, through interactions with others within and outside the department, a positive, professional, team-oriented and service conscious environment that contributes to the goals of the department and reflects the values and mission of CHKDHS.
- Perform outreach to primary sources for practitioners’ information. Obtain and evaluate information from primary sources.
- Perform detailed and thorough review of applications, primary source verifications, and sources provided.
- Recognize potential discrepancies and adverse information, and independently investigate and validate information applications, primary source verifications, or other sources.
- Verify and document expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards.
- Serve as main point of contact for external queries regarding practitioners’ status, providing responses in a timely matter.
- Complete evaluation of application to determine applicant’s initial eligibility for membership/participation, based on approved criteria. Review application and supporting documents for completeness.
- Uniformly apply clearly defined credentialing or privileging processes to all providers.
- Evaluate credentialing/privileging requests and evidence of education, training, and experience to determine eligibility for requested privileges, membership, and/or plan participation.
- Serve as main point of contact for practitioner during application process, providing timely updates and additional information as requested.
- Compile, evaluate, and present the practitioner‑specific data collected for review by one or more decision‑making bodies.
- Perform initial or reappointment/re‑credentialing for eligible practitioners.
- Process requests for privileges.
- Conduct, participate in, and maintain credentialing verification organization (CVO).
- Obtain and assess information from various referral sources.
- Recognize, investigate, and validate discrepancies and adverse information obtained.
- Communicates findings and/or resulting actions to supervisor and department peers (CS II).
- Compile practitioner sanctions, complaints, and adverse data to ensure compliance.
- Demonstrate an understanding of state and regulatory standards.
- Demonstrate an understanding of state and regulatory standards in relation to telehealth and credentialing by proxy.
- Facilitate efficient and cost‑effective due process that complies with an organization’s fair hearing and appeals policy as well as applicable legal and regulatory requirements.
- Identify and report to their supervisor adverse actions taken against a practitioner/provider in accordance with applicable law and contractual requirements.
- Monitor and/or report sanctions and complaints for all practitioners/providers to supervisor.
- Develop informational/educational documents (newsletters, memos) to communicate critical information regarding…
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