Credentialing Coordinator

Job Description

REQUIREMENTS

• High School Diploma or GED required AND
• 3 years medical staff credentialing experience in a healthcare or insurance provider setting; OR
• Associate’s degree and 3 years’ experience performing data collection or data analysis using complex database software systems; OR
• A combination of education and experience.
• Demonstrated software database experience (for efficient generation of letters and other correspondence, activity tracking and report production).
• Familiarity with legal, state, TJC and NCQA guidelines in assuring medical staff compliance with regulatory agencies.
• Displays a credible presence and positive image. Uses appropriate protocol for professional and social situations.
• Organizes work, sets priorities, and determines short- or long-term goals and strategies to achieve them. Aligns communication, people, processes and resources to drive success.
• Establishes productive, cooperative relationships with subordinates, peers, management, and stakeholders both internal and external to the organization. Ability to understand laws, regulatory agency requirements and standards.
• Possess independent problem solving and decision-making abilities.
• Sensitivity to, and natural inclination in, dealing with highly confidential information and communication.
• Proficiency in word processing, computer system work, understanding of data and ability to interpret complex scenarios to assess possible actions and resolutions around credentialing and privileging.

RESPONSIBILITIES

• Processes applications for credentialing and privileging for both initial appointments and reappointments and/or privileging, as defined by established policies and procedures. This process requires detailed knowledge of legal, state, OHSU, DNV, TJC, and NCQA guidelines in assuring compliance with regulatory standards. Recognizes, investigates and validates discrepancies and adverse information obtained from the application, primary source verifications, or other sources. Regular communication with credentialing contacts is central to ensuring timely and accurate completion of the credentialing process.
• Organization and maintenance of practitioner credential files, which contain confidential peer review information. As applicable when processing practitioner applications, this position involves consistent and professional follow-up for outstanding applications, conducting primary source verification, obtaining clinical activity documentation, and other searches such as OIG, Opt-Out and NPDB for presentation to the Medical Executive Committee/Governing Board. The coordinator tracks status of responses, follows up on missing information, and obtains appropriate approvals to assure that the practitioners’ credentials and quality files are complete, accurate, and up to date.
• Maintenance of confidential computerized information in credentialing databases for all applications for appointments and reappointments, as well as any other processing such as additional privileges, temporary privileges, status changes and more. Detailed documentation during all steps in the credentialing process and updating and/or revising information in the database regarding credentialing daily from receipt of application to completion of processing is key.
• Other Duties as Assigned

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