Harvard Pilgrim Health Care

POSITION TITLE: / Credentialing Specialist / PREPARED BY: / Carol Stirling
DEPARTMENT: / Credentialing / DATE: / 3/12/15

SUMMARY OF POSITION:

The Credentialing Specialist is responsible for the review and analysis of the full array of information collected for the purpose of credentialing/recredentialing doctoral and mid-level clinicians and organizational providers according to HPHC Credentialing Policies and Procedures, NCQA standards, State and Federal regulations. The Credentialing Specialist determines the completeness, accuracy and consistency of the data collected and initiates the gathering of additional information from internal and external sources as needed in order to bring files to closure. The Credentialing Specialist determines whether credentialing/recredentialing applicants meet organizational criteria for approval by the Credentials Committee. The Credentialing Specialist is responsible for supporting the non-responder process, as documented, and in support of the HCAS collaborative. The Credentialing Specialist also may handle issues files, which may require further review and research to prepare for the Credentials Committee.

ESSENTIAL FUNCTIONS:

  1. Initiates the collection of data for credentialing through automated credentialing systems and the internet, as determined for issues files.
  2. Maintains non-responder process to ensure all files are complete and ready for Committee.
  3. Analyzes issue provider files for completeness, accuracy, consistency, gaps in time, lack of hospital admitting privileges, low insurance coverage, relevant references, etc. Identifies substantive issues and initiates further data collection as needed, from internal and external sources.
  4. Maintains thorough understanding/knowledge of the NCQA credentialing standards and how they relate to the credentialing/recredentialing processes defined by HPHC, and maintains thorough understanding/knowledge of the HPHC policies including rules, regulations, and legal issues relating to the credentialing/recredentialing processes.
  5. Understands end-to-end process flows in support of HCAS Collaborative. Familiar with all systems that support credentialing processes.
  6. Effectively interfaces with other Credential Specialists and Associates, Provider Processing Center, Committee Reviewers, Provider Consultant Representatives, and/or other department personnel as necessary relating to credentialing/recredentialing.
  7. Coordinates the credentialing/recredentialing process and acts as liaison with hospitals and other health care entities with which we have delegated credentialing.
  8. Processes all issue files, follows non-responder process according to all process steps and within required deadlines.
  9. Maintains production and quality performance standards.
  10. Occasionally may make site visits to entities for auditing purposes.
  11. Participates in status updates to departments including MMQC, PCAC, and other departments as necessary.
  12. Evaluates workflow for speed and efficiency. Evaluates quality improvement and makes suggestions to supervisor and team members for increasing effectiveness. Identifies potential problems and proposes solutions.
  13. Maintains credentialing files and related documents, on issues files.
  14. May participate in training new staff in the credentialing processes and procedures. Oversee work and maintain orderly and systematic flow.
  15. Performs other duties as assigned.

DEPARTMENT SPECIFIC/NON-ESSENTIAL FUNCTIONS:

  1. Other duties as assigned with or without accommodation.

MINIMUM REQUIREMENTS:

Education: / Associates degree or equivalent. Bachelor’s degree preferred. Certification by the National Association of Medical Staff Services is desirable
Experience: / At least 2 years experience as a Credentialing Specialist and/or Medical Staff Coordinator required
Preferred Skills/Qualifications: / Understanding of applicable systems in support of credentialing processes
Skills/Competencies: / -PC proficient
-Knowledge of medical terminology helpful
-Initiative, organizational ability, detail-oriented, proven communication and interpersonal skills, good writing skills
-Ability to maintain confidentiality and work under pressure and deadlines.
Other Skills:

ORGANIZATIONAL RELATIONSHIPS/SCOPE:

Reports to the Supervisor, Credentialing

WORKING CONDITIONS:

Normal office conditions

Some travel to network hospitals and/or provider offices, if needed to support and/or complete credentialing activities

DISCLAIMER:

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.

Please apply here:

NOTE: Please attach current and proposed organizational charts to the job description.