Credentialing Specialist

To apply for this and other open positions, please visit our website at www.chpw.org or use the following link:

http://tbe.taleo.net/NA8/ats/careers/jobSearch.jsp?org=CHPW&cws=1

 

 

 

  COMMUNITY HEALTH PLAN  

Credentialing Specialist

March 2008

 

 

KEY RELATIONSHIPS:

 

Reports To:  Provider Contracting & Credentialing Manager  

 

Supervises:  Non-Supervisory 



Other Key Relationships:  Credentialing Specialists, Provider Relations Coordinators, Credentialing Delegated Oversight Administrator, Administrative Staff

 

FLSA:  Non-Exempt

 

 

POSITION PURPOSE:

 

This position is responsible for coordinating credentialing activities to ensure the Community Health Plan has a provider network of the highest quality. 

 

PRINCIPLE DUTIES:

 

A. Responsible for the timely entry, processing and tracking of credentialing files.

B. Review credentialing files for accuracy and completeness.  Perform additional investigation as determined by document evaluation and facilitate completed credentialing process. 

C. Monitor and assist further investigations as deemed necessary during the credentialing process. i.e. monthly license checks, open complaint follow up

D. Act as liaison between credentialing verification organizations and Community Health Plan.

E.  Attend monthly Provider Credentialing meetings and act on the decisions of the committee regarding files processed.

F.  Initiate provider file updates using the Datasheet as required

G. Prepare inter and intra-company correspondence.

H. Maintain confidential credentialing files and electronic credentialing database.

I.  Serve as contact person for Center and Plan staff regarding credentialing issues.

J. Participate in credentialing team quality audits.

K.  Participate in the development and implementation of departmental policies, procedures, forms

L.  Perform site visits as necessary or requested

M. Other duties as assigned.

 

QUALIFICATIONS: Education

·  Associate degree or 2 years business/technical/vocational training

 Prior Related Experience

·  Three (3) years experience in a healthcare delivery environment or 2 years in credentialing activities.

Licensure and/or Other Requirements:

·  Certified Provider Credentialing Specialist CPCS - Preferred
Certified Professional Medical Services Management CPMSM - Preferred

 

Employment Eligibility:

·  Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

 

Knowledge, Skills, and Abilities

·  Good oral and written communication skills.

·  Ability to meet scheduled deadlines with minimal supervision.

·  Strong organizational skills and accurate work results.

·  Ability to maintain a professional demeanor and confidentiality

·  Maintain knowledge of CMS, NCQA, JCAHO, State and Federal regulations related to health plan credentialing activities

·  Detail oriented.

·  Accomplish responsibilities accurately and expeditiously.

·  Ability to multi-task.

·  Flexible, team player.

·  Self-starter and self-motivated, functions independently with minimal direction

·  Word processing and database computer skills, including Word and Visual Cactus, preferred.

·  Must be able to work with a variety of people and circumstances.

 SENSORY/PHYSICAL/MENTAL REQUIREMENTS

 

Sensory:

·  Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

 

Physical:

·  Extended periods of sitting, computer use, talking and possibly standing.

·  Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

·  Frequent torso/back static position; occasional stooping, bending and twisting. 

·  Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.

 

Mental:

·  Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

 

WORK ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

 

PROTECTED HEALTH INFORMATION (PHI) ACCESS

Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role.  All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164.  In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community Health Plan policies can be cause for termination. 

 

PHI is defined at 164.103 as:

"Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:

 Frequent - The position has frequent and/or daily access and responsibility for PHI.Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

 

The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

 

 

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