Credentialing Specialist

POSITION SUMMARY

Supports departmental activities to ensure quality in conducting, maintaining and communicating physician and provider credentialing, privileging and verifications, in compliance with both facility and accreditation requirements, including National Committee for Quality Assurance (NCQA) Credentialing and Recredentialing (CR) standards. Ensures processes adhere to NCQA guidelines for timeliness, primary source verification, documentation, file integrity, and audit readiness. Serve as a resource to and collaborates with others to advance the quality of practitioners and patient safety.

• Conducts, participates in, and maintains credentialing and privileging.
• Determines applicant's initial eligibility for membership/participation.
• Complies, 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 the application status, including the need for any additional information.
• Participates in the development and standardization of credentialing workflows to align with NCQA accreditation, delegation, and centralized verification organization requirements.
• Performs initial or reappointment/re-credentialing for eligible practitioners.
• Processes requests for privileges.
• Conducts, participates in, and maintains primary source verification.
• Obtains and evaluates information from primary sources.
• Recognizes, investigates, and validates discrepancies and adverse information obtained from the application, primary source verifications, or other sources.
• Verified and documents expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards.
• Provides responses to external queries regarding practitioners' status.
• Obtains and evaluates practitioner sanctions, complaints, and adverse data to ensure compliance.
• Manages the credentialing or privileging process.
• Collaborates with physician leaders to develop and maintain facility-specific, criteria-based clinical privileging system in accordance with regulatory requirements, accreditation standards, and organizational policies.
• Applies clearly defined credentialing or privileging processes to all practitioners/providers.
• Directs initial or reappointment/re-credentialing process for eligible practitioners/providers.
• Maintains credentialing database to ensure that accurate and current information is available to all stakeholders.
• Maintains working knowledge and compliance with departmental policies & procedures, Medical Staff Bylaws, Rules & Regulations, the Joint Commission (TJC), National Committee for Quality Assurance (NCQA), as well as regulatory and accrediting bodies as deemed necessary by administration.
• Participates in an ongoing assessment of governing documents (bylaws, rules and regulations) to ensure continuous compliance.
• Participates in development and implementation of credentialing processes and procedures and advises supervisor of outstanding issues requiring management intervention.
• Other duties within the scope of the non-lead/supervisory job classification to maintain the integrity of credentialing and privileging operations as assigned by department leader.

 

QUALIFICATIONS

EDUCATION: High School Diploma required. Associate degree or Business school preferred.

LICENSE/CERTIFICATION: CPCS and/or CPMSM preferred

EXPERIENCE: Knowledge of computer applications required. Medical Terminology preferred. Prior credentialing experience preferred. Excellent oral and written skills required.

 

PERFORMANCE EXPECTATIONS

Demonstrates the competencies as established on the Assessment and Evaluation Tool for this position.

 

WORK ENVIRONMENT

Potential for exposure to the hazards and risk of the hospital environment, including exposure to infectious disease, hazardous substances, and potential injury. Physical and visual ability required to work computer terminal.

The essential functions for this position are listed on the Ass