MG Credentialing Specialist

Summary:

Under supervision the analyst will maintain and revise all components of the Credentialing databases for the organization. This includes data collection and data analysis of all credentialing and recredentialing information.

The Credentialing Specialist ensures the integrity of all information required in the application and credentialing process. The Credentialing Specialist communicates with both internal and external customers by phone and in writing regarding provider information.

Will coordinate process and analyze all information needed to meet the Board of Registration in Medicine NCQA and network requirements for credentialing and recredentialing. Updates and analyzes provider status as it relates to the network standards. The Coordinator disseminates provider information to all third party payors and other internal departments. Performs in accordance with the facility's policies and procedures. Follows the facility's standards for ethical business conduct. Conducts self as a positive role model and team member. Participates in facility committees meetings in-services and activities.

Responsibilities:

KEY RESPONSIBILITIES:

• In coordination with the Medical Billing Manger the Credentialing Specialist is responsible for collecting and credentialing and recredentialing material from each new and established network provider directly by contacting the provider's primary office location.
• Insures the integrity of and carries out the physician application process in accordance with the Plan:
• Insures the adequacy of all information necessary for PCHI network and RSO membership
• Distributes and collects all application materials
• Reminds and keeps track when physician's licenses are expiring.
• Acts as a resource for all providers or office staff questions regarding the credentialing process
• Identifies for the Director of Administrative Services those issues of broader complexity or sensitivity that may require immediate attention.
• Updates all information on CAQH
• Input provider data in order to maintain integrity of provider status in the database.
• Provide written and or electronic updates to all internal departments as appropriate
• Provide information regarding physicians national data bank issues.
• Working with the Provider Services Staff to provide information updates to network providers
• Provide written notification to all third-party payors regarding provider information and status changes.
• Work with network physicians to insure notification of all provider information and status changes are communicated the PCHI's Credentialing Department.
• In coordination with the Medical Billing Manger responsible for performing an administrative review and identification and analysis for trends deviations quality improvement data patient complaints patient satisfaction and access survey information as it relates to credentialing.
• Responsible for preparing each provider credentialing and recredentialing file for the Credentialing Committee review. Credentialing Specialist will perform an administrative review of each file using protocols established by the Director.
• Works with providers directly and or indirectly to resolve conflicts and issues with regard to provider status and / or provider information.
• Utilize personal computer and various software programs to identify and answer questions posed by internal staff RSO's or providers and / or their office staff
• Under direction initiates coordinates and carries out special projects relating to the enhancements for the provider database and the credentialing process to ensure continuous improvement.
• Other duties as assigned.

Other information:

REQUIRED QUALIFICATIONS:

• Knowledge of organizational policies procedures and systems.
• Knowledge of research methods and procedures sufficient to compile data and prepare reports.
• Keen attention to detail including strong knowledge in healthcare required.

• Requires frequent verbal and written contact with providers office staff RSO's third-party payors hospitals and internal customers.
• Potential contact with the Network Medical Director and Credentialing Committee.
• Coordinator must use discretion when dealing with the Network and all internal departments. Requires confidentiality with regard to provider credentialing and recredentialing documentation

EDUCATION:

• High school diploma or equivalent required
• Bachelor's or Associate's degree preferred

Working Conditions:

• The work environment is one of a typical office work environment. Extensive computer work is an essential portion of the working conditions and necessary for job performance. While performing the duties of this job the employee is frequently required to sit walk; stand; reach with hands and arms; climb or balance; stoop kneel crouch or crawl; and talk or hear. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown Health Medical Group USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union