Job Summary:
Requests and reviews primary source information and verifications, with limited guidance. Identifies and begins to plan for resolution of standard gaps in vendor relationships and escalates, as needed. Serves as a main point of contact for external queries regarding practitioner status. Evaluates applications and supporting documents. Applies and reviews improvements to credentialing and privileging processes. Evaluates standard practitioner sanctions. Participates in surveys and audits of credentialing entities. Supports cost-effective due process. Identifies basic adverse actions/issues. Reviews data to aid in auditing and reconciliation of data. Develops standard informational documents. Maintains working relationships with key stakeholders. Maintains awareness of policies and starts to provide standard consultations. Processes provider enrollment. Gathers and communicates relevant information to appropriate parties. Assists and maintains data systems, applications, and control. Plans and schedules own work to enact and analyze data. Building upon working knowledge of understanding of database structures and data.
Essential Responsibilities:
- Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members.
- Listens to, addresses, and seeks performance feedback.
- Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage/improve them.
- Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work.
- Assesses and responds to the needs of others to support a business outcome.
- Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship.
- Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information.
- Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
- Participates in training and regulatory awareness by assisting in the facilitation of orientation and training to newly appointed physician leaders for effective oversight and management of their departments credentialing, proctoring, privileging, and reappointment processes, with general directions.
- Assists in quality assurance, improvement, and resolution by obtaining and learning to evaluate standard practitioner sanctions, complaints, and adverse data to ensure compliance, with general directions.
- Processes provider enrollment by gathering and performing detailed and thorough review of the standard information used to submit the enrollment applications.
- Conducts primary source verification and management by requesting, obtaining, and reviewing information from primary source verifications to evaluate applications and provided sources for alignment, with limited guidance.
- Assists in governing databases by building working knowledge of structures and data within a computerized database of physician data for use in the credentialing and appointment process, in alignment with department guidelines.
- Applies and ensures control and application of data systems by building upon knowledge of data structures, system functions, and coordinating the access and controls of data.
- Enacts and analyzes data by planning and scheduling own work to ensure the efficient file completion, conduct privileging analyses, and verify privileging to the appropriate specialty/facility, based on data, with minimal day-to-day supervision.
- Enacts credentialing and privileging maintenance and management by planning and scheduling own completion and evaluation of application and supporting documents for completeness and to determine applicants initial eligibility for membership/participation.
Minimum Qualifications:
- Associates degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum one (1) year(s) of experience in clinical credentialing, accreditation and regulation, licensing, health care, quality or a directly related field OR minimum two (2) years' experience in clinical credentialing, accreditation and regulation, licensing, or a directly related field.
Additional Requirements:
- Knowledge, Skills, and Abilities (KSAs): Project Management; Credentialing IT Application Software
#J-18808-Ljbffr
