Credentialing Coordinator II

Employer: Planet Professional

Supports all department activities related to the credentialing and recredentialing of Medical Practitioners and Organizational Providers (Providers), in accordance with the Plans policies and procedures.

Key Functions/Responsibilities:

• Independently reviews practitioner and facility credentialing files to ensure completion and accuracy of information, per Plans policies.
• Ensures all files are completed in a timely manner, and meets the appropriate turnaround times
• Initiates the collection of all pertinent information/documentation from the practitioner, facility administrator or appropriate office staff.
• Verifies credentials through the appropriate primary sources
• Independently identifies substantive adverse issues and initiates further data collection from internal and external sources.
• Analyzes provider files to identify discrepancies with information. Creates thorough and complete summary profiles for Medical Director and Credentialing Committee review.
• Assists with the departments ongoing monitoring activities.
• Reviews appropriate reports and databases against the Plans provider networks and completes outreach to providers regarding licensure actions.
• Reviews sanction and exclusion sources to ensure that providers going through initial credentialing or recredentialing are not currently debarred, suspended or otherwise excluded from participation in Medicare, Medicaid or any other federal or state health care programs.
• Responsible for managing internal provider data queues (e.g. OIG, Terminations).
• Responsible for reviewing and researching routine expirables reports (e.g. License, Board Certification).
• Organizes and maintains assigned electronic credentialing files. Responsible for updating credentialing information within Visual Cactus and the Onyx provider database.
• Maintains detailed log of all pending work.
• Assists department leadership with preparing for NCQA audits
• Supports special projects and completes other duties as assigned.

Must Haves:

• 3 or more years of credentialing experience in a health plan or a hospital medical staff services department
• A strong working knowledge of Microsoft Office products
• Maintains an intermediate understanding of the National Committee for Quality Assurance (NCQA) accreditation standards, MassHealth, NH DHHS and other Federal/State credentialing requirements

Competencies, Skills, and Attributes:

• Strong oral and written communication skills
• Ability to interact with other departments within the organization, and with external audiences
• Strong analytical skills
• Ability to compose accurate and comprehensive file summaries
• Accurate and detail oriented
• Flexible and able to work with minimal supervision
• Ability to manage multiple tasks and possess excellent organizational and time management skills

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