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Job Description SummaryThe Medical Staff Credentialing and Provider Enrollment Coordinator (MSP) is a hands-on administrative professional responsible for managing departmental activities to ensure quality in conducting, maintaining, and communicating physician credentialing, privileging, and primary source verifications while simultaneously enrolling employed provider with the payers. They serve as a resource, support to the Chief Medical Officer, and the Director of Medical Staff Services in collaboration with clinical providers and support staff to advance the quality of practitioners and patient safety.
Job DescriptionEssential Functions:Conducts, participates in and maintains credentialing and privilegingDetermines applicant’s initial eligibility for membership/participationCompiles, evaluates, and presents the practitioner-specific data collected for review by one or more decision-making bodiesAnalyzes application and supporting documents for completeness and informs the practitioner of application status, including the need for any additional information.Uniformly applies clearly defined credentialing or privileging processes to all practitioners/providersEvaluate credentialing/privileging requests and evidence of education, training, and experience to determine eligibility for requested privilegesComplies with internal and external requirements related to verifying the status of all practitioner/provider expirable(s) (e.g., licenses, certifications) by querying approved sources and recommending action(s) to ensure compliance.Performs initial and reappointment/re-credentialing for eligible practitionersConducts, participates in and maintains primary source verificationRecognizes, investigates, and validates discrepancies and adverse information obtained from the application, primary source verifications, or other sourcesVerifies and documents expirable(s) using acceptable verification sources to ensure compliance with accreditation and regulatory standardsProvides responses to external queries regarding practitioners’ statusConducts, participates in and maintains compliance with accreditation standards and regulatory requirementsDevelops and/or updates applicable governing documents (bylaws, credentialing policies, rules) that support and direct organizational practices and ensures complianceIdentifies and reports adverse actions taken against a practitioner/provider in accordance with applicable law and contractual requirementsMonitors and/or reports sanctions and complaints for all practitioners/providers to recommend action by medical staff and/or organizational leadership.Conducts, participates in and maintains provider enrollment for Southeast Health Medical GroupManages provider enrollment process, initial enrollment and re-credentialingAccountable for directly entering and updated provider data into the data repository of credentialing (CAQH) systemResponsible for the ongoing maintenance of existing providers including but not limited to the submission of maintenance forms to update personal and practice demographic data for providers and billing updatesResponsible for follow-up and resolution of enrollment credentialing with Patient Financial Services to monitor and resolve third party billing and compliance issuesResponsible for ensuring compliance with payers, including submission of monthly, quarterly and yearly rosterAccountable for submitting termination requests to all health plans in a timely mannerConducts, participates in and maintains current clinical competency evaluationsAnalyze and prepare reports regarding practitioner/provider performance improvement and ensures quality/competency data is clear, concise, and structured.Recognize, investigate, and validate discrepancies and adverse information obtainedCommunicates findings and/or resulting actions to director and department leadership.Performs other duties as requested by Director that do not compromise moral code of conduct or protocols set in place for patient or employee safety.Supervised PositionsNone

Qualifications

Minimum Education RequiredAssociate’s degree in business, management, or health related fieldMinimum Education PreferredBachelor’s degree in business, management, or health related field;The equivalent combination of education and experience includes six (6) years or more of administrative experience and the completion of post-secondary education that pertains to the administrative or health related field.Post-secondary education would include administrative training, management training, provider enrollment and/or credentialing training.Minimum Experience RequiredThree (3) to five (5) years of administrative experience.Minimum Experience PreferredThree (3) to five (5) years of progressive experience in healthcare field

Required Knowledge/ Skills/ Abilities

Certified Provider Credentialing Specialist (CPCS) within three (3) years of startAn eagerness to expand knowledge and is trainable.Organizes work, effectively prioritizes, and sets short- or long-term goals and strategies for achievement. Aligns communication, people, processes, and resources to drive success.Exhibits confidence and professional diplomacy with identifying, organizing, facilitating and/or sustaining mutually beneficial partnerships and alliance with people at all levels internally and externally.Facilities positive, professional, and constructive dialogue while demonstrating a sound knowledge of subject matterUnderstands concepts, key functions, and terminology and work products pertaining to legal, information technology, and clinical competence evaluation.Organize information and data to identify/explain trends, problems, and their causes. Compares, contrasts, and combines information to determine underlying issuesSolid computer skills with Microsoft Office Suite, Internet applications, database softwareExcellent negotiation, decision making, and time management competencePerson in this position is required to understand, agree upon and follow our Six Ground Rules:No excuses.We are a team.Bring up your ideas.Poor performance will be addressed.‘That’s not my job’ is not acceptableManage Up.

ShiftDayShift Details8:00 am - 4:30 pm
FTE1
TypeRegular
Join one of Forbes 500 best mid-sized employers in America.Equal Employment EmployerSoutheast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.