Summary

The Credentialing Coordinator completes credentialing and re-credentialing processes for all providers.

Essential Duties and Responsibilitie

• Credentials new providers and re-credentials existing providers to include completing the applications for:
  • Hospital and facility privileges
  • DEA and medical license address corrections
  • SVMIC malpractice insurance
  • Council for Affordable Quality Health Care (CAQH) - houses all providers information
  • NPI databank
  • Disclosure of Ownership
  • Participation in Medicare; and
  • Participation in State of Franklin Healthcare’s payer agreements.
• Coordinates credentialing paperwork with clinic managers to meet identified timeframe. Follows-up to ensure paperwork is returned.
• Completes and maintains credentialing file for each provider.
• Maintains contact with the insurance carrier to ensure applications are received and processed properly.
• Maintains knowledge of individual insurance carrier requirements for credentialing.
• Completes provider re-credentialing applications requested by third party payers and facilities.
• Maintains and updates proper credentialing materials (state licenses, DEA, SVMIC, curriculum vita, and continuing medical education certificates) for providers’ files.
• Maintains and updates providers’ participation status with insurance carriers for CBO staff and SOFHA clinic staff.
• Maintains and updates provider rosters.
• Maintains list of contact information and process by payer in the credentialing manual.
• Appropriately evaluates insurance denials for “non-participating physician” or “out-of-network.” Contacts insurance carriers as needed to correct participation status so that claims can be refiled and/or reprocessed correctly.

Other

• Compiles information and prepares reports.
• Maintains records.
• Participates in educational activities.
• Regular and in-person attendance as scheduled and required to perform essential job functions.
• Follows organizational policies and procedures, including State of Franklin Healthcare Associates Compliance Manual, Code of Ethics and Business Standards, HR Policies and Procedures Manual, Team Member Handbook, OSHA Manual and any other policies or procedures for the job function, department, location or clinic.
• Performs other duties as assigned.

Direct Reports

None

Qualifications

Knowledge of application procedures for licensures, privileges and insurance carrier participation, insurance carrier operating procedures and practices and ability to complete the applications accurately and efficiently. Skill in using computer, calculator, copy and fax machine.

Education

High school diploma or GED

Experience

Two years of clerical experience with demonstrated initiative and self-direction or additional related education may be substituted for the two years of clerical experience.

Certificates, Licenses, Registrations

None

Competencies

Teamwork: Maintains a positive working relationship with team members; acknowledges strengths and contributions of others; supports team goals and objectives.

Compassion: Professional and respectful to patients, co-workers and others; remains calm when faced with challenging or difficult situations; manages and resolves conflict in a constructive manner.

Extra Effort: Makes the best use of time during work hours; looks for opportunities to help others when assigned work is complete; goes above and beyond to ensure priorities are achieved.

Excellence:

• 
  Quality/Continuous Improvement: Ensures accuracy and completeness of work performed; contributes ideas and methods for improvement; receptive to suggestions and new ideas; accepts constructive feedback and demonstrates improvement.

• 
  Job Knowledge/Technical Skill: Proficient in required skills for duties assigned; able to navigate and resolve unexpected situations.

• 
  Productivity/Dependability: Responsive to direction and instructions; demonstrates ability to set priorities; completes appropriate quantity of work within assigned time limits; follows through on assignments and notifies supervisor if unable to complete; exhibits good attendance record (excluding approved leave); gives appropriate notification of absence and schedules time off appropriately.

Working Conditions

Work is performed in a medical office environment involving contact with patients, physicians, staff, insurance carriers and other business partners. Occasional local travel between work sites and additional hours, including evening or weekend work, may be necessary.

Physical Requirements