Job Summary:

• Assisting new physicians with acquiring DEA and state licenses, completing malpractice insurance applications, and board certification
• Credentialing and re-credentialing all physicians with commercial health plans and managed care companies
• Confirms correct linkage and effective dates with commercial health plans for all physicians and mid-levels
• Responsible for enrolling physicians and mid-levels with Medicaid, Medicaid CMO’s, and Medicare
• Responsible for assisting physicians with completing applications to acquire and maintain hospital privileges at local hospitals and surgery centers
• Utilizes CAQH (online credentialing databank) and credentialing software to keep track of physicians' credentialing information
• Acts as a liaison with Office Managers to obtain necessary credentialing information and signatures from physicians on an ongoing basis
• Reserves the right to add or change duties at any time.
• Creatively and collaboratively resolve technical and non-technical processing issues with carriers
• Open to taking on additional tasks to ensure the success of the team

Skills on Resume: 

• Credentialing Expertise (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Credentialing Software Proficiency (Hard Skills)
• Attention to Detail (Soft Skills)
• Effective Communication (Soft Skills)
• Problem-Solving Abilities (Soft Skills)
• Organizational Skills (Soft Skills)
• Adaptability (Soft Skills)

Job Summary:

• Manage and monitor enrollment and terminations of new and existing providers, ensuring all regulations and documentation requirements are met.
• Complete provider credentialing and re-credentialing applications, monitor applications and follow
• Database maintenance, update accordingly with information regarding employee training, licenses, education, continuing education, and relevant job experience.
• Verification of both individual and facility accreditation, maintaining records of verification and working with auditors
• Conduct full-cycle credentialing process for new and existing providers, ensuring all are credentialed with the appropriate health plans for practice location.
• Create accounts for providers and enroll providers into EMR & EHR system, updating changes
• Provides regular credentialing status reports to corresponding departments in a timely manner.
• Staying abreast of all current health plans and company requirements for credentialing providers to ensure successful audits.
• Keeps current with legal issues necessary for the implementation of the bylaws etc. 
• Oversees provider information in online credentialing databases and systems.

Skills on Resume: 

• Regulatory Knowledge (Hard Skills)
• Credentialing Expertise (Hard Skills)
• Database Management (Hard Skills)
• Verification Skills (Hard Skills)
• System Integration (Hard Skills)
• Reporting (Hard Skills)
• Knowledge of Health Plans (Hard Skills)
• Legal Compliance (Hard Skills)

Job Summary:

• Obtain all necessary credentialing information and documentation required for the payer enrollment process and verify complete standard applications for new hires
• Ensure the timely submission and completion of new hire PSV initial and re-credentialing events
• Facilitate the pre-filling, sending and receiving of accurate and complete credentialing information
• Tracks and reports progress in the credentialing database, and performs follow-up activities until the enrollment profile is completed
• Notify payers of professional and clinical staff updates such as service locations, periodic roster updates, name changes, official notices, etc. on an ongoing basis
• Completes all re-credentialing and revalidation commercial and government requests for individual providers, service locations and organization
• Ensures all individuals meet the qualifications of NCQA Credentials Verification Organization (CVO) standards as well as other regulatory requirements and agreements.
• Works proactively to resolve issues before providers and/or patients are impacted.
• Performs primary source verification for applicants.
• Collaborates with personnel in other departments and organizations.
• Ensures appropriate documentation is maintained and that information is easily retrievable.

Skills on Resume: 

• Attention to Detail (Soft Skills)
• Organizational Skills (Soft Skills)
• Communication Skills (Soft Skills)
• Regulatory Knowledge (Hard Skills)
• Problem-Solving Skills (Soft Skills)
• Database Management (Hard Skills)
• Document Management (Hard Skills)
• Verification Skills (Hard Skills)

Job Summary:

• Maintains knowledge of current requirements for credentialing providers.
• Prepare and/or update the provider’s application for newly affiliated and existing providers.
• Processes applications for appointment and reappointment for One Call.
• Build a knowledge base for payer requirements and forms.
• Tracks license, and professional liability expirations for appointed providers.
• Completes provider credentialing and re-credentialing applications for escalated cases and monitors applications and follows-up
• Ensures credentialing timeliness meets and/or exceeds the NCQA expectations by following up in a timely manner and escalating items as designated by the policy.
• Maintains appointment files and information in credentialing.
• Provides excellence in customer service for internal and external customers when handling communications, whether oral or written.
• Ensure all workflow items are completed within the set turn-around time, meeting expectations.
• Responsible for exceptions in committee decision follow-up.

Skills on Resume: 

• Application Management (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Tracking and Monitoring (Hard Skills)
• NCQA Compliance (Hard Skills)
• Customer Service Excellence (Soft Skills)
• Workflow Management (Hard Skills)
• Committee Decision Follow-up (Hard Skills)

Job Summary:

• Successfully manages, coordinates, and monitors the EHN initial credentialing and re-credentialing processes for the organization (practitioners and facilities).
• Maintains timelines on credentialing schedules, and communicates with practitioners and other departments to update information
• 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 and 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 the 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 in accordance with established policies and procedures
• Monitors and maintains health care provider credentialing expires.

Skills on Resume: 

• Credentialing Process Management Hard Skills
• Attention to Detail Soft Skills
• Communication and Coordination Soft Skills
• Committee Support Hard Skills
• Regulatory Compliance Hard Skills
• Problem-Solving Soft Skills
• Data Management Hard Skills
• Time Management Soft Skills

Job Summary:

• Responds to correspondence both internally and externally
• Ensures compliance with State and Federal requirements and Accreditation standards.
• Generates queries and reports from the provider database
• Establishes professional relationships with EHN staff to ensure information is updated correctly and promptly.
• Functions as a resource to customers and on credentialing issues as appropriate.
• Develops credentialing policies by NCQA and regulatory standards.
• Performs pre-delegation and annual audits by the organization.
• Review credentialing delegation agreements to ensure compliance with NCQA Standards and Guidelines.
• 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 both within the department and with other departments.

Skills on Resume: 

• Compliance Knowledge (Hard Skills)
• Database Management (Hard Skills)
• Communication Skills (Soft Skills)
• Professional Relationship Management (Soft Skills)
• Credentialing Expertise (Hard Skills)
• Customer Service (Soft Skills)
• Analytical Skills (Hard Skills)
• Team Collaboration (Soft Skills)

Job Summary:

• Credential and re-credential new Physicians, existing Physicians, and Allied Health Professionals with necessary hospitals and health plans
• Determine the applicant’s eligibility for membership/participation
• Gather all required documents, identify potential issues and determine if further investigation or information is necessary and make appropriate inquiries
• Obtain and evaluate information from primary sources
• Analyze application and supporting documents for completeness according to accreditation and regulatory standards
• Compile, log, and submit the practitioner-specific data collected and assembled during the application process
• Regularly follow up and provide responses to queries from entities to assist them in completing the credentialing process until approval
• Coordinate orientations and EMR systems training, as applicable
• Maintain regular reports and communications with company management, providers, and employees regarding network participation status and credentialing/contracting decisions
• Audit and preserve credentials files and records according to policy and procedures
• Ensure all provider TSCAs, licenses, and certificates are current while consistently keeping hospitals and MCOs up to date with these provider documents

Skills on Resume: 

• Eligibility Determination (Hard Skills)
• Document Gathering (Hard Skills)
• Information Evaluation (Hard Skills)
• Document Analysis (Hard Skills)
• Data Compilation (Hard Skills)
• Follow-up and Response (Soft Skills)
• Coordination and Training (Soft Skills)
• File Auditing (Hard Skills)

Job Summary:

• Facilitates all aspects of credentialing and privileging for initial appointments, reappointments, and privileging. 
• Processes initial credentialing and re-credentialing for all agency health professionals (employees and volunteers) promptly and tracks the application from time of receipt to Committee/Board approval.
• Reports changes in, all applicable standards, laws, regulations, and Credentialing and Privileging Policies and Procedures.
• Responsible for the accuracy and integrity of credentialing and privileging database systems. 
• Ensures tasks are performed to completion with minimal errors and are accurate, thorough, and timely.
• Serves as CCH liaison to third-party payer plans for the credentialing of providers through CAQH Proview.
• Maintains the confidentiality of all business/work and health staff/volunteer information. 
• Assists in managing the flow of information between individual credentialed employees/volunteers, Human Resources and Revenue Cycle.
• Works independently with internal and external colleagues enrolling providers in Medicaid and Medicare.
• Assists providers in obtaining Medicaid and Medicare provider numbers for billing and reimbursement purposes.

Skills on Resume: 

• Privileging Expertise (Hard Skills)
• Database Management (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Detail-Oriented (Soft Skills)
• Communication Skills (Soft Skills)
• Confidentiality (Soft Skills)
• Independence and Initiative (Soft Skills)
• Provider Enrollment (Hard Skills)

Job Summary:

• Processes initial credentialing and re-credentialing applications
• Screens provider's applications and supporting documentation to ascertain eligibility.
• Collects information from National Practitioner Data Bank (NPDB), the applicant and malpractice insurer and other relevant sources.
• Captures primary source documentation in computer databases
• Ensures compliance with applicable laws, regulations, procedures and policies.
• Assists in developing processes to drive efficiency across multiple corporate and operational teams
• Coordinates and maintains CAQH and NPPES credentialing for all providers
• Coordinates DOT registration, and maintains licensing annual checks
• Coordinates with finance for insurance credentialing purposes
• Collaborate with Operations and Legal Counsel to write NP/PA collaboration agreements
• Coordinates provider relations processes including communication content development, Continuing Medical Education, Activities, contractual questions and administrative policy and procedure development.

Skills on Resume: 

• Credentialing and Re-Credentialing Expertise (Hard Skills)
• Data Management (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Process Improvement (Hard Skills)
• Coordination and Communication (Soft Skills)
• Attention to Detail (Soft Skills)
• Project Management (Hard Skills)
• Content Development (Soft Skills)

Job Summary:

• Monitors NPDB continuous query summary reports.
• Performs complete file reviews for credentialing audits. 
• Validates that all required credentialing elements are complete and accurate.
• Provides all necessary documentation for payer plan audits and provider enrollment denials.
• Participates in organizational activities pertaining to Credentialing, Human resources, quality assurance, DATA, health and safety, and workforce development, and promotes good working relationships with all CCH and RPMC staff.
• Makes him/herself available by cell phone to assist providers, CCH staff, and the Credentialing and Privileging Committee Members.
• Completing enrollment applications for Medicaid, Medicare, and new commercial payers 
• Initiating credentialing follow-up in response to business changes and M&A transactions 
• Ongoing credentialing tasks including payer credentialing, Medicare/Medicaid revalidation, Accreditation credentialing, license renewals for all services, reporting, and registered agent maintenance 
• Maintaining a filing system for all credential-related documentation 

Skills on Resume: 

• File Review (Hard Skills)
• Documentation for Audits (Hard Skills)
• Communication (Soft Skills)
• Collaboration (Soft Skills)
• Credentialing Follow-Up (Hard Skills)
• Filing System Management (Hard Skills)
• Adaptability (Soft Skills)