Responsible for daily operations of the credentialing department to develop, manage and monitor processes and procedures that support the credentialing, re-credentialing, and provider set-up. This role will also assist the provider relations department with special projects as assigned. Facilitates all credentialing functions, such as application management, vendor coordination, Credentialing Committee preparation and support, policy development, delegation audits, review of delegated credentialing agreements and special projects as assigned. Manages the flow of information to EHN team and customers in a timely and confidential manner. Ensures compliance with accrediting and applicable regulatory agencies (e.g., NCQA, JC) in regard to credentialing practitioners and facilities.
Specific responsibilities of the role include:
1. Credentialing Responsibilities.
Successfully manages, coordinates, and monitors the EHN initial credentialing and recredentialing processes for the organization (practitioners and facilities).
Maintains timelines on recredentialing schedules, communicates with practitioners and other departments to update information as needed.
Supports EHN Medical Director, Credentialing Committee, EHN staff and departments to meet business needs.
Works with CVO coordinating file transfers to implement credentialing and ensure accurate completion of credentialing to meet EHN leveling criteria.
Coordinates receipt of credentialing applications following processing and primary source verification; performs review and analysis and identifies “red flag” items; prepares files for review and recommendation.
Prepares the Credentialing Committee agenda with EHN Medical Director, sends out meeting notices, takes minutes, and provides follow up as directed by Medical Director and Credentialing Committee members. Coordinates credentialing end-of-committee processes to ensure notification to health care providers, internal departments, and databases.
Identifies issues that require additional investigation and/or follow-up.
Processes other credentialing requests, as assigned, in accordance with established policies and procedures.
Monitors and maintains health care provider credentialing expirables.
Monitors NPDB continuous query summary reports.
Responds to correspondence both internally and externally.
Ensures compliance with State and Federal requirements and Accreditation standards.
Generates queries and reports from provider database as requested.
Functions as a resource to customers and on credentialing issues as appropriate.
Develops credentialing policies in accordance with NCQA and regulatory standards.
Performs pre-delegation and annual audits as required by the organization.
Reviews credentialing delegation agreements to ensure compliance with NCQA Standards and Guidelines.
2. Provider Relations Responsibilities:
Provider outreach to be conducted and onsite visits as needed.
Network management related tasks such as data analysis and special projects.
Provide ongoing education to network providers regarding policies, contract terms and other network operation components.
3. Other Responsibilities:
Assists with other duties as assigned.
Demonstrates ability to listen, communicate effectively and express ideas clearly following appropriate channels of communication.
Communicates appropriately and clearly to providers, staff, director, and administrative team.
Maintains a good working relationship to both within the department and with other departments.
Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team. Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workplace.
Basic computer skills
Minimum five (5) years health plan credentialing experience
NCQA, State and Federal requirements and regulation knowledge
CPCS and/or CPMSM certification through the National Association of Medical Staff Services (NAMSS)
Facility and Professional credentialing experience
Led by industry veterans with decades of experience in the healthcare market, Employers Health Network is a partner to employers, healthcare providers and brokers. In this role, our mission is to empower our customers—employers searching for a long-term answer to healthcare spending—in their mission to provide quality care at an affordable price. We bring clarity and certainty to healthcare decision making.