Job Description

POSITION SUMMARY:

Under the direction of the Senior Director of Credentialing Verification Office with daily activities supervised by the Credentialing Manager, this position performs all duties for initial and recredentialing file processing per NCQA, The Joint Commission, state and federal regulations and Medical Staff By-Laws.

KEY RESPONSIBILITIES:

Responsibilities include, but are not limited to:

  • Coordinates the credentialing and recredentialing process for assigned providers.
  • Collects and maintains all pertinent information from the provider. Communicates consistently with providers and provider office staff in a timely and effective manner to follow up to obtain required documents on a timely basis in alignment with processing guidelines.
  • Verifies all credentialing elements, including but not limited to, education, training, board certification, work history, licensure and certifications, malpractice coverage
  • Through a variety of primary sources as appropriate per NCQA and The Joint Commission standards.
  • Enters data accurately and completely in the credentialing software.
  • Analyzes provider files for completeness, accuracy, consistency, gaps in work history, relevant references, etc. Identifies issues and initiates further data collection as needed. Communicates handoff to appropriate Medical Staff Office.
  • Maintains thorough understanding of NCQA, The Joint Commission, and Commonwealth of Massachusetts credentialing standards.
  • Manages expirables as assigned.
  • Organizes and maintains paper and electronic files as required.
  • Meets assigned file processing quality and quantity standards.
  • Generates routine reports to assure timeliness of verifications, appropriate recredentialing dates, and processing of expirables.
  • Performs routine file audits.
  • Other duties as assigned.

REQUIRED KNOWLEDGE & SKILLS:

· Strong organizational, problem solving, and prioritization skills as demonstrated by the successful and timely completion of assignments.

· Excellent verbal and written communication skills, ability to interact with all levels of personnel

· Keen attention to detail

· Experience working in a team-oriented, collaborative and matrix environment

· Working knowledge of Microsoft Office, Skype and other software used in daily work

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

· Education: Bachelor's degree or equivalent education and experience

· Experience:

Three or more years of credentialing experience in a medical staff services department or managed care plan desired.

Experience with Initial and Reappointment file processing according to NCQA and TJC standards.

National Certified Provider Credentialing Specialist Certification preferred.

Application Instructions

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