Position: Credentialing Specialist

Subtype: (PSV, Internal Committee)

Monogram Health is seeking an individual who has worked at either a large health plan credentialing department, large clinical organization/provider group, medical staff office or credentials verification organization. The credentialing specialist contributes to the ongoing advancement of the organization's goals by ensuring practitioners are credentialed internally using vetted processes and procedures. The department's mission is to implement industry best practices to efficiently credential and recredential health care practitioners and reduce processing timeframe with delegated payors for earlier revenue cycle release.

The credentialing specialist identifies, analyzes, and resolves information discrepancies, and time gaps that could adversely affect our organization's ability to credential and/or privilege providers. The credentialing specialist coordinates with medical staff, credentialing and peer review committees, and other key stakeholders to ensure compliance with credentialing standards and timeframes. Responsible for maintaining timely, accurate and comprehensive data in credentialing software and shared drives. The credentialing specialist contributes to maintaining consistent, accurate, detailed and organized records that can be subject to internal, health plan and NCQA audits at any time.

The credentialing specialist must have overall knowledge of credentialing process, know the required credentials for health care professionals and utilize the appropriate resources to complete Primary Source Verification (PSV) according to National Committee for Quality Assurance (NCQA) and state regulatory standards. The credentialing specialist must demonstrate a thorough knowledge on credentialing policies, guidelines, and regulations for the Monogram Health internal credentialing process.

Prior to applying to Monogram Health, ideal candidates may have had successful roles such as: Credentialing Verifier, Credentialing Specialist, Credentialing Account Manager, Credentialing Team Lead, Medical Staff Office Professional, Provider Enrollment Specialist, PES Account Manager, PES Team Lead

Possessing these traits may indicate high compatibility for role: Investigative, flexible, detailed and process oriented, affinity for accuracy, deadline conscientious, excellent documentation skills, adaptable, strategic and organized

Roles and Responsibilities

• Review and process internal credentialing applications for healthcare providers, ensuring accuracy and completeness of information.
• Send secure credentialing documents for electronic signature via Adobe Docusign or similar platform.
• Maintain detailed and up-to-date provider credentialing and verification records in compliance with regulatory standards
• Document and note all critical credentialing lifecycle events in credentialing software (ie. Application Received, Requests for Information, PSV, QA Review, Committee Review and Approval)
• Understands the importance of organized documentation and timely follow-up
• Communicate clearly with providers, healthcare leadership and administrative staff as needed to provide timely responses upon request on day-to-day credentialing issues as they arise.
• Develops and maintains strong relationships with practitioners and operations team to facilitate timely credentialing and recredentialing
• Primary point of contact for credentialing discrepancies
• Review Clinician Master Roster for new credentialing assignments and maintain credentialing database with required information
• Manage credentialing verification tracking workflows
• Coordinate with onboarding credentialing specialist for seamless transition to PSV within required timeframes
• Verify provider credentials including licenses, DEA/CDS, certifications, education, work history, professional liability claims, Medicare/Medicaid sanctions, and licensure disciplinary actions/sanctions. Verifications may be completed via online search, web crawlers, phone, fax, email and mail
• Conducts ongoing monitoring processes including license, DEA, professional liability, board certification expirations, and sanctions for all contracted provider/practitioners
• Queries results directly from approved primary sources included (but not limited to): NPDB, OIG, SAM, Medicare Opt Out Affidavit List, National Student Clearinghouse, AMA, AOA, ANCC, AANP, ECFMG, state licensing boards
• Follow Licensing and Credentialing Escalation Pathway for practitioners or applications with outstanding items/information needed to finalize the credentialing process
• Roster practitioner credentialing applications via CAQH Participating Organization account and other state specific credentialing databases (ie CCVS, OneHealthPort ProviderSource)
• Informs management regarding the status of departmental operations and provider credentialing issues of concern.
• Support management with administrative components of Monogram Credentialing Committee and Monogram Peer Review Committee such as:
• Able to coordinate committee meetings, distribute agendas
• Able to participate at committee meetings as subject matter expert and take detailed meeting minutes, complete administrative follow-up actions as a result of committee discussion
• Identify and communicate files with discrepancies, flags that will require MCC review
• Generate Practitioner Checklist and compile credentialing file for management and committee review
• Generate and send appropriate credentialing correspondence (including determination letters) to practitioners within NCQA and state mandated timeframes
• Manage internal MCC email inbox
• Send confidentiality statements to voting committee members and guests
• Able to complete routine tasks reliably
• Familiar with Medicare Advantage credentialing requirements
• Generate reports and maintain accurate records of provider credentialing activities
• Provide ad-hoc reporting and special projects when requested
• Assist management in all credentialing aspects of regulatory reviews including, but not limited to, state and federal regulations, NCQA and CMS
• Prepares or reviews all pre-audit documents to assure accuracy
• Produce and submit delegated rosters to contracted clients
• Maintain confidentiality of information and security of credentialing files
• Able to take advantage of department training/resources for self-guided learning
• Willingness to be cross trained in payor enrollment, medical licensing and hospital privileging as additional coverage support needs arise

Position Requirements

• Bachelor's Degree preferred
• 3-5 years' experience required
• Proficiency in Microsoft office applications (e.g. Word, Excel, PowerPoint)
• Knowledge of Medicaid and/or Medicare credentialing requirements
• Knowledge of NCQA accreditation credentialing survey requirements
• Ability to research data and draw conclusions
• Must be able to work in a self-directive manner and manage multiple simultaneous time-sensitive deliverables.
• Must possess excellent verbal and written communication skills

Benefits

• Opportunity to work in a dynamic, fast-paced and innovative care management company that is transforming the delivery of kidney care
• Competitive salary and opportunity to participate in company's bonus program
• Comprehensive medical, dental, vision and life insurance
• Flexible paid leave & vacation policy
• 401(k) plan with matching contributions

About Monogram Health

Monogram Health is a next-generation, value-based chronic condition risk provider serving patients living with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to fill systemic gaps and transform the way nephrology, primary care and chronic condition treatment are delivered. Monogram's innovative, in-home approach utilizes a national nephrology practice powered by a suite of technology-enabled clinical services, including case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs across the healthcare continuum. By focusing on increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing greater health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.

Equal Opportunity Employer

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