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Job Description Summary

The Medical Staff Credentialing and Provider Enrollment Coordinator (MSP) is a hands-on administrative professional responsible for managing departmental activities to ensure quality in conducting, maintaining, and communicating physician credentialing, privileging, and primary source verifications while simultaneously enrolling employed provider with the payers. They serve as a resource, support to the Chief Medical Officer, and the Director of Medical Staff Services in collaboration with clinical providers and support staff to advance the quality of practitioners and patient safety.

Job Description

Essential Functions:

Conducts, participates in and maintains credentialing and privileging

• Determines applicant’s initial eligibility for membership/participation

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

• Analyzes application and supporting documents for completeness and informs the practitioner of application status, including the need for any additional information.

• Uniformly applies clearly defined credentialing or privileging processes to all practitioners/providers

• Evaluate 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/provider expirable(s) (e.g., licenses, certifications) by querying approved sources and recommending action(s) to ensure compliance.

• Performs initial and reappointment/re-credentialing for eligible practitioners

Conducts, participates in and maintains primary source verification

• Recognizes, investigates, and validates discrepancies and adverse information obtained from the application, primary source verifications, or other sources

• Verifies and documents expirable(s) using acceptable verification sources to ensure compliance with accreditation and regulatory standards

• Provides responses to external queries regarding practitioners’ status

Conducts, participates in and maintains compliance with accreditation standards and regulatory requirements

• Develops and/or updates applicable governing documents (bylaws, credentialing policies, rules) that support and direct organizational practices and ensures compliance

• Identifies and reports adverse actions taken against a practitioner/provider in accordance with applicable law and contractual requirements

• Monitors and/or reports sanctions and complaints for all practitioners/providers to recommend action by medical staff and/or organizational leadership.

Conducts, participates in and maintains provider enrollment for Southeast Health Medical Group

• Manages provider enrollment process, initial enrollment and re-credentialing

• Accountable for directly entering and updated provider data into the data repository of credentialing (CAQH) system

• Responsible for the ongoing maintenance of existing providers including but not limited to the submission of maintenance forms to update personal and practice demographic data for providers and billing updates

• Responsible for follow-up and resolution of enrollment credentialing with Patient Financial Services to monitor and resolve third party billing and compliance issues

• Responsible for ensuring compliance with payers, including submission of monthly, quarterly and yearly roster

• Accountable for submitting termination requests to all health plans in a timely manner

Conducts, participates in and maintains current clinical competency evaluations

• Analyze and prepare reports regarding practitioner/provider performance improvement and ensures quality/competency data is clear, concise, and structured.

• Recognize, investigate, and validate discrepancies and adverse information obtained

• Communicates findings and/or resulting actions to director and department leadership.

• Performs other duties as requested by Director that do not compromise moral code of conduct or protocols set in place for patient or employee safety.

Supervised Positions

• None

  Qualifications

Minimum Education Required

• Associate’s degree in business, management, or health related field

Minimum Education Preferred

• Bachelor’s degree in business, management, or health related field;

• The equivalent combination of education and experience includes six (6) years or more of administrative experience and the completion of post-secondary education that pertains to the administrative or health related field.

• Post-secondary education would include administrative training, management training, provider enrollment and/or credentialing training.

Minimum Experience Required

• Three (3) to five (5) years of administrative experience.

Minimum Experience Preferred

• Three (3) to five (5) years of progressive experience in healthcare field

Required Knowledge/ Skills/ Abilities

• Certified Provider Credentialing Specialist (CPCS) within three (3) years of start

• An eagerness to expand knowledge and is trainable.

• Organizes work, effectively prioritizes, and sets short- or long-term goals and strategies for achievement. Aligns communication, people, processes, and resources to drive success.

• Exhibits confidence and professional diplomacy with identifying, organizing, facilitating and/or sustaining mutually beneficial partnerships and alliance with people at all levels internally and externally.

• Facilities positive, professional, and constructive dialogue while demonstrating a sound knowledge of subject matter

• Understands concepts, key functions, and terminology and work products pertaining to legal, information technology, and clinical competence evaluation.

• Organize information and data to identify/explain trends, problems, and their causes. Compares, contrasts, and combines information to determine underlying issues

• Solid computer skills with Microsoft Office Suite, Internet applications, database software

• Excellent negotiation, decision making, and time management competence

• Person in this position is required to understand, agree upon and follow our Six Ground Rules:

• No excuses.

• We are a team.

• Bring up your ideas.

• Poor performance will be addressed.

• ‘That’s not my job’ is not acceptable

• Manage Up.

Shift

DayShift Details

8:00 am - 4:30 pm

FTE

1

Type

Regular

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Equal Employment Employer

Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.