Credentialing Specialist

Overview

The Credentialing Specialist I in the Medical Staff office plays a critical role in ensuring that Covenant Healthcare professionals meet the highest standards of quality care and competency. The Credentialing Specialist I will coordinate the full lifecycle of Health Professional credentialing and re-credentialing for initial appointments, reappointments and locum tenens coverage which includes the principal objective is to validate the credentials, qualifications, competency, education, training and experience of Covenant Healthcare professionals.

Demonstrates excellent customer service performance in attitude and actions that are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant Healthcare and the commitment to Extraordinary Care for Every Generation.

Responsibilities

Credentialing

• Responds to requests for appointments and reappointments by sending applications and appropriate clinical privileges/service authority forms utilizing the MD Staff Software system.
• Completes evaluation of initial and reappointment applications to determine applicant's eligibility for Medical Staff membership and patient care privileges. Analyzes application and supporting documents for completeness and returns those applications found to be incomplete.
• Coordinate the initial and reappointment credentialing/privileging process for all physicians, Advanced Practitioners (NPs, Pas, CRNAs) and Non-physician practitioners.
• Obtaining accurate primary source verification of health professional credentials, including all licenses, education, hospital and employment affiliations, references, criminal background check, federal sanctions, National Practitioner Data Bank, American Medical Association, American Osteopathic Association and ECFMG to validate Health Professionals are fully qualified to perform the privileges requested.
• Maintain accurate and complete credentialing/privileging files confirming all Health Professionals are cleared and Board approved before providing patient care.
• Reviews privileges requested by the healthcare provider, compared to their education and training, contrasted with relevant experience to recommend if the individual is qualified to provide safe and competent patient care.
• Obtains necessary privileging documentation and clinical activity for establishment and maintenance of competency requirements as defined by ACHC standards and State & Federal regulations.
• Performs the final analysis of a Health Professional’s application, with the assistance of the Manager and/or Credentialing Specialist II as needed, before deeming the credentialing file complete and ready for advancement to Section Chief, Department Chair and Credentials Committee review and final board approval.
• Identifies red flags during the credentialing and privileging process exercising analytical skills and judgment, to attempt to resolve locally or determine, with consult with the Manager, if the issue should be escalated.
• Composes appointment/reappointment provider summaries for Section Chief and Department Chair review applying Medical Staff Bylaws and credentialing policies.
• Prepares application for MD Staff Virtual Committee review and recommendation to Section Chief, Department Chair and Credentials Committee members.
• Scheduling and attending meetings, data entry/integrity, record management and performing other administrative tasks as assigned.
• Improves professional growth, knowledge of medical staff credentialing role to maintain efficiency and effectiveness by participating in professional organizations, attending seminars and reading journals and publications addressing medical staff services activities and trends.
• Processes Medical Staff, APP and non-physician practitioner resignations archiving files, updating MD Staff and adding to Credentials Committee agenda.
• Process change of status requests as needed.
• Process additional privilege requests in accordance with best-evidenced based practice, TJC standards, and State and Federal guidelines.
• Assists with the Mackinaw Surgery Center reappointments under the direction and guidance of the Credentialing Specialist II.
• Assists with the onboarding and training of new Credentialing Specialist I staff as directed by the Medical Staff Services Manager and/or Credentialing Specialist II.
• Coordinates and supports annual Medical Staff dues collection process through initiating invoices, collecting payments, managing the Journal Entry process and performing required follow-up to ensure all Medical Staff dues payments are collected. Logs all payments received in MD Staff for accounting purposes and prepares and performs deposit.
• Assists Medical Staff Manager with biannual Medical Staff elections.
• Collects application fees, logs all payment received in MD Staff for accounting purposes and prepares and performs deposits.

Compliance & Standards

• Stays current on federal, state, and accreditation requirements (CMS, ACHC, State, etc.)
• Track expiration dates for licensure, certifications, and accreditations communicating with Health Professionals on a regular basis to prevent lapses/expiration.
• Safeguards provider and facility compliance with healthcare laws and standards.
• Apply Medical Staff Bylaws and Credentialing and privileges processes uniformly to all applicants and reapplicants.

Data & Reporting

• Maintain up-to-date credentialing/privileging databases and file systems.
• Ensure confidentiality and compliance with HIPAA and other privacy regulations.
• Assists with running reports and creation of reports for leadership and regulatory agencies, as requested by Medical Staff Services Manager and/or Credentialing Specialist II.

Collaboration & Communication

• Partner with HR, Physician Recruiters, Physician Liaisons, Payor Enrollment, PHO and leadership to keep credentialing processes on track.
• Regularly provides updates and proactive recommendations on credentialing status and timelines to applicants and leadership.
• Readily respond to inquiries from Health Professionals, accreditation organizations, external vendors, leadership, etc. related to the credentialing and privileging processes.
• Participates in the Michigan Association of Medical Staff Services state-wide organization to network and advance medical staff skills through education and collaboration with other state members.
• Performs other duties as assigned.

Qualifications

EDUCATION/EXPERIENCE

• Associate's Degree in Health Services Administration or Business required. In lieu of Associate’s degree, high school diploma with two (2) years of advanced administrative assistant experience, credentialing/privileging, physician office, healthcare/hospital, health plan and/or payor enrollment experience will be accepted.
• Experience in medical staff services, graduate medical education, healthcare compliance, physician/hospital experience or insurance credentialing/health plan/payor enrollment preferred.
• Basic knowledge of Medical Terminology preferred.
• Proficiency in MS Office Suite and skills to utilize common office software and machines required. Experience with electronic credentialing software MD Staff or other credentialing software preferred.

KNOWLEDGE/SKILLS/ABILITIES

• Ability to recognize and question responses to queries and competency requests as recommended by best-evidenced based practice and outlined by the Medical Staff Bylaws/Credentialing Policies and Procedures.
• Fundamental knowledge of credentialing processes and healthcare compliance.
• Superior organizational skills to meet credentialing and privileging timelines.
• Detail oriented to ensure capturing data accurately to prevent potential errors and to ensure capturing Health Professional and other data accurately.
• Strong interpersonal skills with ability to communicate well with others, proficiency in listening, writing, and speaking.
• Excellent written communication skills for constructing minutes and correspondence, and excellent verbal skills for communicating individually and in group meetings.
• Excellent typing, word processing and computer skills including Microsoft Office.
• Able to balance multiple priorities to meet deadlines.
• Self-directed requiring minimal supervision
• Maintains high level of confidentiality and ensures Peer Protection of Credentials application collected materials, meetings and conversations.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant hearing, near vision and midrange vision.
• Frequent lifting up to 10 lbs.
• Frequent standing, walking, sitting, far vision, depth perception, visual accommodation, color vision and field of vision.
• Occasional lifting, carrying, pushing, pulling, twisting, reaching, handling, feeling and talking.

EDUCATION/EXPERIENCE

• Associate's Degree in Health Services Administration or Business required. In lieu of Associate’s degree, high school diploma with two (2) years of advanced administrative assistant experience, credentialing/privileging, physician office, healthcare/hospital, health plan and/or payor enrollment experience will be accepted.
• Experience in medical staff services, graduate medical education, healthcare compliance, physician/hospital experience or insurance credentialing/health plan/payor enrollment preferred.
• Basic knowledge of Medical Terminology preferred.
• Proficiency in MS Office Suite and skills to utilize common office software and machines required. Experience with electronic credentialing software MD Staff or other credentialing software preferred.

KNOWLEDGE/SKILLS/ABILITIES

• Ability to recognize and question responses to queries and competency requests as recommended by best-evidenced based practice and outlined by the Medical Staff Bylaws/Credentialing Policies and Procedures.
• Fundamental knowledge of credentialing processes and healthcare compliance.
• Superior organizational skills to meet credentialing and privileging timelines.
• Detail oriented to ensure capturing data accurately to prevent potential errors and to ensure capturing Health Professional and other data accurately.
• Strong interpersonal skills with ability to communicate well with others, proficiency in listening, writing, and speaking.
• Excellent written communication skills for constructing minutes and correspondence, and excellent verbal skills for communicating individually and in group meetings.
• Excellent typing, word processing and computer skills including Microsoft Office.
• Able to balance multiple priorities to meet deadlines.
• Self-directed requiring minimal supervision
• Maintains high level of confidentiality and ensures Peer Protection of Credentials application collected materials, meetings and conversations.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant hearing, near vision and midrange vision.
• Frequent lifting up to 10 lbs.
• Frequent standing, walking, sitting, far vision, depth perception, visual accommodation, color vision and field of vision.
• Occasional lifting, carrying, pushing, pulling, twisting, reaching, handling, feeling and talking.

Credentialing

• Responds to requests for appointments and reappointments by sending applications and appropriate clinical privileges/service authority forms utilizing the MD Staff Software system.
• Completes evaluation of initial and reappointment applications to determine applicant's eligibility for Medical Staff membership and patient care privileges. Analyzes application and supporting documents for completeness and returns those applications found to be incomplete.
• Coordinate the initial and reappointment credentialing/privileging process for all physicians, Advanced Practitioners (NPs, Pas, CRNAs) and Non-physician practitioners.
• Obtaining accurate primary source verification of health professional credentials, including all licenses, education, hospital and employment affiliations, references, criminal background check, federal sanctions, National Practitioner Data Bank, American Medical Association, American Osteopathic Association and ECFMG to validate Health Professionals are fully qualified to perform the privileges requested.
• Maintain accurate and complete credentialing/privileging files confirming all Health Professionals are cleared and Board approved before providing patient care.
• Reviews privileges requested by the healthcare provider, compared to their education and training, contrasted with relevant experience to recommend if the individual is qualified to provide safe and competent patient care.
• Obtains necessary privileging documentation and clinical activity for establishment and maintenance of competency requirements as defined by ACHC standards and State & Federal regulations.
• Performs the final analysis of a Health Professional’s application, with the assistance of the Manager and/or Credentialing Specialist II as needed, before deeming the credentialing file complete and ready for advancement to Section Chief, Department Chair and Credentials Committee review and final board approval.
• Identifies red flags during the credentialing and privileging process exercising analytical skills and judgment, to attempt to resolve locally or determine, with consult with the Manager, if the issue should be escalated.
• Composes appointment/reappointment provider summaries for Section Chief and Department Chair review applying Medical Staff Bylaws and credentialing policies.
• Prepares application for MD Staff Virtual Committee review and recommendation to Section Chief, Department Chair and Credentials Committee members.
• Scheduling and attending meetings, data entry/integrity, record management and performing other administrative tasks as assigned.
• Improves professional growth, knowledge of medical staff credentialing role to maintain efficiency and effectiveness by participating in professional organizations, attending seminars and reading journals and publications addressing medical staff services activities and trends.
• Processes Medical Staff, APP and non-physician practitioner resignations archiving files, updating MD Staff and adding to Credentials Committee agenda.
• Process change of status requests as needed.
• Process additional privilege requests in accordance with best-evidenced based practice, TJC standards, and State and Federal guidelines.
• Assists with the Mackinaw Surgery Center reappointments under the direction and guidance of the Credentialing Specialist II.
• Assists with the onboarding and training of new Credentialing Specialist I staff as directed by the Medical Staff Services Manager and/or Credentialing Specialist II.
• Coordinates and supports annual Medical Staff dues collection process through initiating invoices, collecting payments, managing the Journal Entry process and performing required follow-up to ensure all Medical Staff dues payments are collected. Logs all payments received in MD Staff for accounting purposes and prepares and performs deposit.
• Assists Medical Staff Manager with biannual Medical Staff elections.
• Collects application fees, logs all payment received in MD Staff for accounting purposes and prepares and performs deposits.

Compliance & Standards

• Stays current on federal, state, and accreditation requirements (CMS, ACHC, State, etc.)
• Track expiration dates for licensure, certifications, and accreditations communicating with Health Professionals on a regular basis to prevent lapses/expiration.
• Safeguards provider and facility compliance with healthcare laws and standards.
• Apply Medical Staff Bylaws and Credentialing and privileges processes uniformly to all applicants and reapplicants.

Data & Reporting

• Maintain up-to-date credentialing/privileging databases and file systems.
• Ensure confidentiality and compliance with HIPAA and other privacy regulations.
• Assists with running reports and creation of reports for leadership and regulatory agencies, as requested by Medical Staff Services Manager and/or Credentialing Specialist II.

Collaboration & Communication

• Partner with HR, Physician Recruiters, Physician Liaisons, Payor Enrollment, PHO and leadership to keep credentialing processes on track.
• Regularly provides updates and proactive recommendations on credentialing status and timelines to applicants and leadership.
• Readily respond to inquiries from Health Professionals, accreditation organizations, external vendors, leadership, etc. related to the credentialing and privileging processes.
• Participates in the Michigan Association of Medical Staff Services state-wide organization to network and advance medical staff skills through education and collaboration with other state members.
• Performs other duties as assigned.