The Credentialing Coordinator is responsible for initial credentialing and re-credentialing Third Street practitioners and other licensed staff to comply with applicable professional and regulatory requirements as well as ensuring enrollment with participating health care plans. Credentialing functions include, but are not limited to, processing credentialing applications, performing primary source verification’s and maintaining the credentialing database in accordance with internal policies and procedures, health plan contracts, HRSA, FTCA, The Joint Commission and applicable state and federal requirements. The Credentialing Specialist will be responsible for managing our payor contracts and establishing and coordinating the negotiation of the terms and fees applicable to those contracts. The Credentialing Specialist works with the Director of Compliance to ensure compliance with federal laws, rules, and regulations pertaining to Medicare and Medicaid programs. This position manages new applications for and maintaining all organizational licenses, certifications, and registrations to ensure compliant business operations.

MAJOR AREAS OF RESPONSIBILITY:

• Process all new initial credentialing files for providers, other licensed clinical practitioners, and other clinical staff.
• Ensure all credentialed staff are current with licensures and certifications.
• Re-credential per policy Licensed Independent Practitioner, other licensed clinical practitioners, and other clinical staff.
• Enroll and manage the credentialing processes with new payors.
• Educate billing and clinical teams on the contracts' terms, including any value-based, outcomes-based, or alternative payment terms of contracts
• Build and maintain collaborative relationships with provider representatives for each payor, emphasizing major payor partners, including Medicaid Managed Care Plans.
• Submit credentialing rosters to the centralized credentialing system(s) or payors MITS monthly according to the intervals required per payor or payor type
• Initiate and support the practitioner application process by sending, receiving and analyzing practitioner documents and data import to determiner completeness in preparation for the credentials verification process.
• Responsible for gathering, verifying highly confidential and sensitive health care practitioner credentials consistent with departmental guidelines and accreditation standards.
• Efficiently perform all aspects of credentialing verification, including initial credentialing and re-credentialing to ensure current credentials and timely handoff and/or review of approval of practitioner files.
• Respond to all practitioner, health plan and internal inquiries in a timely manner.
• Monitor expiring licensure, board and professional certifications and other expiable documents within the prescribed timeframe.
• Maintain practitioner paper and electronic data files, utilizing credentialing software and CAQH to submit practitioner data as required to credential individual practitioners.
• Responsible for accurate data entry to ensure the integrity of credentialing information in applicable database(s).
• Monitor, maintain, and coordinate reviews and updates to all payor contracts for medical, dental and behavioral health services.
• Collaborate with practitioners, department managers and/or external agencies to facilitate and ensure smooth hand off to various departments during the credentialing process.
• Use critical thinking skills to conduct follow-up with individual practitioners and internal and external entities to resolve discrepancies identified during the credentialing process.
• Conduct sanctions and compliance monitoring and alert clinical department leaders of any undisclosed negative findings immediately.
• Keep clinical department leaders informed of potential credentialing or enrollment issues.
• Other duties as assigned.

Personal Contact: Frequent contact with staff of community agencies, health plans, regulatory agencies and the general public. Daily contact with agency staff. Must develop and maintain positive relationship with all of the above.

Essential Characteristics:

• Commitment to agency mission statement
• Ability to develop trust and effective working relationships with staff members and external and internal professionals
• Ability to organize time and prioritize projects efficiently and effectively
• Effective leadership abilities

Required Knowledge, Education and Experience:

• Associate’s degree is preferred; or an equivalent combination of education and/or experience.
• Minimum of 3 years’ experience in provider credentialing.
• Experience should include responsibility for medical and professional credentialing processes, and credentialing requirements.

• Healthcare industry experience.