Credentialing Coordinator

Job Summary

The Credentialing Coordinator position is responsible for leading, coordinating, monitoring, and maintaining the credentialing and re-credentialing process. The Credentialing Coordinator ensures that the Nexus/ProPeer panels are properly trained, licensed and certified as mandated by URAC requirements. The Credentialing Coordinator is responsible for facilitating the credentialing, orientation process and communication of our contracted physicians, allied health professionals, physician assistants, and nurse practitioners through an organized and systematic routine. 

Essential Job Functions 

• Leads, coordinates, and monitors the review and analysis of Nexus/ProPeer panel members and accompanying documents, ensuring continued applicant eligibility

• Facilitates all aspects of Nexus/ProPeer credentialing, including initial panel entry, re-credentialing, expirable process and required documentation

• Ensures interpretation and compliance with the appropriate accrediting and regulatory agency (URAC), while developing and maintaining a working knowledge of the statutes and laws relating to credentialing

• Ensures a Best Practice level of interpretation and integrity when processing credentialing documentation

• Responsible for the accuracy and integrity of credentialing database system and related applications

• Work in cooperation with the Physician Recruiters communicating verbally and electronically with potential panel members (physicians and allied health professionals)

• Communicate promptly and professionally by providing all credentialing paperwork and packets with instructions to each potential panel member regarding the credentialing process

• Directly responsible for receiving, organizing, and documenting all needed credentialing documents of contracted physicians and allied health professionals

• Responsible for primary source verification of all credentialing documents

• Directly responsible for ensuring full completion of all documents and individual audit of any outliers

• Analytically and structurally seek out inconsistencies in paperwork or written/verbal communication, and work quickly to rectify them

• Conducts thorough background investigation, research and primary source verification discrepancies and ensures appropriate follow-up

• Submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act

• Responsible for initiating and obtaining various regulatory reports for incoming panel members to include: OIG, SAM, Texas Medical Board, HCSC, etc.

• Prepares credentials file for completion and presentation to Credentialing Committee, ensuring file completion with time periods specified

• Utilizes credentialing database, optimizes efficiency and performs query, report, and document generation

• Maintain databases and required spreadsheets containing new and/or updated information regarding Nexus panel training, licenses, education, continuing education and URAC required documentation

• Track panel member referrals and notify Director of Operations when referral fee payment becomes eligible

• Responsible for the annual re-credentialing process & manages the expiration of all documents and maintenance of communication to ensure all licenses/documentation are kept current

• Responsible for providing clients with updated credentialing information, changes of information, and the credentialing materials when authorized and necessary

• Maintain and update physician electronic files by properly saving all physician/allied health providers’ documents in the correct format

• Conducts internal file audits at the request of the Credentialing Manager

• Maintain and update “Doctor Birthday Calendar” with dates of physician/allied health professionals’ birthdays; work in conjunction with Credentialing Manager to ensure mail out

• Conduct physician orientation calls for newly credentialed physicians and allied health professionals entering the panel

• Update and maintaining credentialing workflow documents assisting operations staff of the demographic information of the panel

• Maintain an organized filing system in Outlook, retaining all email communication to quickly access physician communication

• Collaborate with the Director, Corporate Services, to issue required memorandums to the panel

• Update and maintain departmental monthly analytic reports

• Complete all credentialing applications by providing accurate and clearly written information for each physician and allied health professional after they have been approved at the credentialing meeting

• Other duties as assigned

 Knowledge and Abilities:

• Strong understanding of credentialing standards (e.g., NCQA, URAC, Joint Commission, CMS, state regulations)

• Strong attention to detail and the ability to identify errors or inconsistencies

• Strong organizational and task prioritization skills

• Ability to communicate effectively, both orally and in writing

• Program planning and implementation skills

• Knowledge of related accreditation and certification requirements

• Familiarity with primary source verification and re-credentialing procedures

• Ability to interpret and verify licenses, certifications, and malpractice history

• Ability to analyze, interpret and draw inferences from research findings and prepare reports

• Informational research skills

• Ability to use independent judgment to manage and impart confidential information

• Database management skills such as querying, reporting, and document generation

• Ability to make administrative/procedural decisions and judgments to resolve credentialing discrepancies

• Proficiency in Microsoft Office Sute (Excel, Word, Outlook) and database management

• Ability to work both independently and as part of a team

Education and Experience:

• Must have at least 1year of experience in medical credentialing, provider enrollment, or a related field
• Experience working with hospitals, insurance companies, or healthcare organizations
• A minimum of 1 years’ experience within a multi-task driven work environment, requiring a  high-level of organizational skills
• Bachelor’s or associate degree is preferred but is not required
• Prior Utilization Review (UR) Administrative support experience is preferred

Driving Essential: No 

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity (Our EEO Statement)

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.