Credentialing and Privileging Specialist

Company :

Job Description : 

GENERAL OVERVIEW:

This job coordinates and implements the credentialing and privileging activities within the Credentialing and Privileging Office to include appointment, reappointment and ongoing verification activities of the Medical Staff and Allied Health Professional Staff of AHN entities. Responsible for the investigation and documentation of practitioner credentials, utilizing specialized knowledge to obtain verification of all aspects of a practitioner's background, training and past practice. Understands credentialing and privileging requirements of the Department of Health, Joint Commission, NCQA, URAC and other governmental requirements, and performs in accordance with these standards. Generates and maintains accurate documentation that may be reviewed and judged for acceptability by state and federal licensing agencies. Handles customer questions and complaints.

ESSENTIAL RESPONSIBILITIES

• Reviews medical staff and allied health practitioner appointment and reappointment applications for appropriateness of data, as measured against department and external requirements. Determines primary sources for verifications in accordance with accreditation standards and AHN entity agreements with the Credentialing and Privileging Office. Verifies and documents such verification as required by external standards in the practitioner file. Performs follow-up and second source verification as judged to be necessary. Verifies practitioner meets criteria for requested privileges, performs  focused professional practice evaluations, reappointments, changes in status or privileges and temporary privileges as needed. (50%)
• Evaluates all verifications for possible discrepancies with practitioner information and the need for further investigation. Notifies supervisors and management of adverse or questionable responses from the verification process. Creates scanned references of adverse or potentially adverse information for facility downloads when appropriate. (15%)
• Documents the results of all verifications and inquiries, as required by external regulatory standards and agreements between the Credentialing and Privileging Office AHN entities. Maintains and utilized a the credentialing and privilieging software system for tracking activities (i.e. date each query was initiated, author and method of verification, privilege information, etc.). (15%)
• Maintains credential files for the Medical Staff and Allied Health Professional Staff according to the Medical Staff Bylaws and all federal/state regulatory and/or accrediting agencies. (15%)
• Assists in organization and development of monthly Credentials Committee and Allied Health Professional Subcommittee agendas in order to comply with Managed Care requirements. (5%)
• Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

• High School / GED
• 3 years of general office administration work in a business, education, or healthcare environment

Preferred

• Associate's Degree
• 3 years with physician credentialing and privileging, medical education, hospital environment, health insurance or managed care
• 1 year in customer service
• Certified Provider Credentialing Specialist (CPCS) OR Certified Professional Medical Services Management (CPMSM)

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirement

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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