Credentialing Services Specialist III

Requests and reviews primary source information and verifications, with regular review from manager. Identifies and plans for resolution of standard and nonstandard gaps in vendor relationships and escalates, as needed. Serves as a main point of contact for external queries regarding practitioner status. Evaluates applications and supporting documents. Applies and begins to suggest improvements to credentialing and privileging processes. Evaluates standard and nonstandard practitioner sanctions. Participates in surveys and audits of credentialing entities. Supports cost-effective due process. Conducts audits of data between different departments, with regular review. Assists in the facilitation of orientation and training to newly appointed physician leaders. Develops standard and nonstandard informational documents. Maintains working relationships with key stakeholders. Maintains awareness of policies and starts to provide standard and nonstandard consultations. Processes provider enrollment. Gathers and independently communicates relevant information to appropriate parties. Applies and ensures control of data systems and applications. Independently enacts and analyzes data. Maintains database structures and data.

• Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.


• Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.


• Enacts credentialing and privileging maintenance and management by: independently completing evaluation of applications and supporting documents for completeness and to determine applicants initial eligibility for membership/participation; serving as main point of contact for practitioner during application process, providing timely updates and additional information as requested; preparing and completing moderately complex documents (e.g., Board Reports, Delegation reports) related to practitioner-specific data for presentations to decision-making bodies (e.g., committees); conducting initial or reappointment/re-credentialing for eligible practitioners; independently applying defined and suggesting improvements to credentialing and privileging processes for all practitioners/providers, with general review; and maintaining documents needed for presentation.


• Enacts and analyzes data by: independently ensuring efficient file completion, conducting privileging analyses, and verifying privileging to the appropriate specialty/facility, based on data, with occasional review; and leveraging standard and nonstandard tools and policies to support knowledge management, record-keeping, and internal and external communication.


• Applies and ensures control and application of data systems by: maintaining data structures, system functions, creations of workflows, portal management and coordinating the access and controls of data; interpreting guidelines to enact auditing, assessing, procuring, implementing, effectively utilizing, and maintaining practitioner/provider and delegated credentialing processes and information systems (e.g., files, reports, minutes, databases) as outlined; and reviewing current and beginning to suggest new processes (e.g., electronic board memos) to ensure compliance.


• Assists in governing databases by: maintaining structures and data within a computerized data base of physician data for use in the credentialling and appointment process, in alignment with department guidelines, with review.


• Conducts primary source verification and management by: requesting, obtaining, and reviewing information from primary source verifications to evaluate applications and provided sources for alignment, with regular review from manager; identifying standard and non-standard gaps and opportunities in vendor relationships, and escalating to manager as appropriate; independently identifying, supporting creation of, and executing plans for resolution of inaccurate primary source process, verifications, applications, and adverse information, escalating as appropriate; independently verifying and documenting expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards, with occasional review; and serving as main point of contact for external queries regarding practitioners status, responding in a timely manner.


• Processes provider enrollment by: gathering and performing detailed and thorough review of the standard and nonstandard information used to submit the enrollment applications; preparing and submitting data and applications to the contracted and government payors in a manner commensurate with their expectations, policies and accreditation standards, with regular review; independently communicating enrollment status to all stakeholders in a clear and timely manner; and notarizing public documents.


• Assists in quality assurance, improvement, and resolution by: obtaining and evaluating standard and nonstandard practitioner sanctions, complaints, and adverse data to ensure compliance, with regular review from manager; participating in ongoing assessments of standard and nonstandard governing documents (e.g., bylaws/rules and regulations/policies and procedures) to ensure continuous compliance; participating in surveys and audits of credentialing entities (e.g., CMOs, delegates and health plans for NCQA); facilitating efficient and cost-effective due process that complies with internal fair hearing and appeals policies and external legal and regulatory requirements, with regular review; identifying, escalating, and preparing standard and nonstandard adverse actions/issues (e.g., sanctions and complaints) to the credentialing committee taken against a practitioner/provider in accordance with applicable law and contractual requirements to the necessary parties; and conducting audits and reconciliations of data between different departments, monitoring credentialing and contracting, with regular review.


• Participates in training and regulatory awareness by: assisting in the facilitation of orientation and training of newly appointed physician leaders for effective management of their departments credentialing, proctoring, privileging and reappointment processes, with regular review from manager; developing standard and nonstandard informational/educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies; beginning to develop and cultivate working relationships with key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making; and maintaining awareness of current internal policies and relevant external regulations and starting to provide standard and nonstandard consultative expertise to internal parties.