Position Summary

Oversees, manages, and coordinates all day-to-day functions associated with the centralized credentialing process of medical staff services for initial applications and reappointment applications for providers within The Spartanburg Regional Health System. Oversees data management of provider information/data in the credentialing database, verifies data quality/timelines, understands the impact of the data on internal network applications, internal and external customers. Recommends actions for identified non-compliance with credentialing processes or data integrity. Assignments are planned and executed assuring compliance with established policies and procedures, Bylaws, Credentialing Policy, Dependent Policy, accreditation, and payor standards. This position is a liaison with both internal and external agencies involved in the credentialing process (Employment and Recruitment, Employee Health, Federal and State agencies etc.)

In addition, Credentialing Manager is specifically responsible for system wide entities served through the Medical Staff Office including but not limited to: Spartanburg Medical Center, Pelham Medical Center, Union Medical Center, Spartanburg Hospital for Restorative Care, Ambulatory Surgery Center of Spartanburg, Ambulatory Surgery Center of Pelham, Regional Health Plus, Ellen Sager Nursing Center and Woodruff Manor.

 

Minimum Requirements

Education 

Associate Degree

 

Experience

Knowledgeable in CMS, DNV, and NCQA regulations. 

At least 5 years' experience as a medical staff professional or other appropriate professional training.

 

Licenses/Registrations/Certifications

Certified Provider Credentialing Specialist (CPCS) certification or Certified Professional Medical Service Management (CPMSM) certification required.

 

Core Job Responsibilities

Manage the daily work assignments for credentialing and provider data entry team to validate and assure all aspects of the initial credentialing, re-credentialing, ongoing motoring, and privileging, to include, but not limited to, primary source verification and overseeing the Medical Staff onboarding processes for all incoming Physicians and Allied Health Professionals. Assignments are planned and executed assuring compliance with established policies and procedures, Bylaws, Allied Health Professional Policy, and accreditation standards.

Manage provider data by conducting productivity metrics and regular audits to ensure the accuracy and integrity of provider information in credentialing databases and systems, collaborating with medical staff director to develop and implement data quality initiatives, automate data entry processes, and resolve data discrepancies efficiently.

Mentors and trains credentialing staff and other department staff that interact with the credentialing function and serve as a resource.

Initiates monthly "draft" report regarding credentialing status of initial and reappointment for Medical Staff Director to formulate Credentials Committee agenda for each entity. This agenda is acted on by Credentials Committee, Medical Executive Committee, and Board of Trustees.

Reviews and presents credentialing files during audits for other departments (e.g,, regulatory bodies, payor audit, etc.).

Manages a bi-weekly credentialing meeting with credentialing specialist, credentialing assistant, and credentialing analyst. Records and maintains minutes of meeting and follow up as indicated.

Ensures applications to physicians, allied health professionals, and dependents meet threshold eligibility criteria and initial request are sent electronically within 2 business days of authorization and credentialing data is entered into credentialing database completely with any issues flagged and assure issues are addressed per policy (e.g. eligibility for application).

Ensures credentialing applications and supplement forms are in accordance with accreditation standards, regulatory and payor requirements, and policies and procedures.

Verifies, researches, and responds to emails, telephone inquiries, and written inquiries from providers and other departments, pertaining to provider participation and credentialing status in a professional and courteous manner.

Works closely with the Director of Medical Staff Services and department chairs keeping leadership informed on applications in the credentialing process, and obtaining the appropriate signatures, if applicable.

Obtains appropriate approval leadership signatures and notifies the applicant in a timely fashion of their appointments and updates the appropriate credential files. Expect appointment to be complete within 45 days unless delays in primary source verifications.

Reviews and interprets applicable accreditation, licensure, and other regulatory requirements for recommendations that will ensure that the organizational bylaws and policies meet requirements (per entity).

Initiate the current IT system security access process for Medical Staff.

Supports Employee Health processes required for Health status (TB, FIlu, etc.) and such reporting as may be required.

Immediately enters clinical privileges so that clinical staff has current physician information as required by CMS, DNV, DHEC, Medical Staff and Board of Trustees.

Demonstrates the ability to adapt to innovative ideas and changes in the workload and work environment.

Assists in regulatory surveys and payor audits.

Provide input and maintenance in the development of a departmental operating and capital budget. Considers efficiency and cost.

Effective written and verbal communication required.

Establish and maintain good networking relationships with internal and external departments (e.g., Human Resources, Employee Health, IT, Recruitment and Physician Offices).

Performs all clerical and other work-related duties of the position.

Continues to improve professional growth and knowledge related to credentialing and payor enrollment.

Completes mandatory education and training courses in a timely manner. Seeks out additional educational opportunities to continuously improve skills, education, and knowledge.