Credentialing Coordinator

Mercy Health Corporation

Janesville (WI)

On-site

USD 30,000 - 48,000

Full time

14 days+

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Benefits offered by this job

Medical, Dental, Vision

Paid time off

Tuition reimbursement

Well-being Programs

On-Demand Pay

Job summary

Mercyhealth is seeking a Credentialing Specialist to oversee credentialing and recredentialing for medical and behavioral health providers within our network. You will ensure NCQA standards and regulatory compliance, maintain directories, and generate reports while safeguarding confidentiality.

This role requires credentialing experience, familiarity with NSA/NCQA guidelines, and proficiency in Microsoft Office and credentialing software.

Qualifications

Associate's degree with 1 year credentialing experience preferred, or 2+ years in credentialing
Experience with regulatory guidelines (NSA/NCQA) is a plus
Proficient in credentialing software and database management

Responsibilities

Maintain credentialing processes for providers (initial, recredentialing, add-ons)
Ensure NSA/regulatory compliance and confidentiality
Enter and track information across credentialing systems
Prepare reports and audits for management and committees
Manage provider directories and MA rosters

Skills

Interpersonal communication

Written communication

Attention to detail

Time management

Education

Associate's degree in healthcare administration or related field

Tools

Microsoft Office Suite

Credentialing software

Job description

ESSENTIAL DUTIES AND RESPONSIBILITIES

Maintains high quality, timely and accurate credentialing processes of medical providers, behavioral health providers, and allied healthcare professionals based upon system policies and procedures.

Manages the entire credentialing process by entering, logging, scanning information into the system for initial credentialing, re-credentialing, add-on applications and maintenance.

Completes and ensures compliance, confidentiality and delivery of required information to all credentialed providers in a timely manner.

Manages all aspects of credentialing and recredentialing in accordance with MercyCare policies and procedures, NCQA Standards, State and Federal regulatory guidelines.

Point person for the No Surprises Act (NSA) to ensure regulatory compliance.

Ensures that all credentials are current and complete pursuant to expiration date of medical licensure, board certification, professional liability insurance coverage, DEA and other pertinent information per MercyCare policy/procedure.

Manages collection of all information received. Follow-up on missing items/documentation/incomplete forms. Submits follow-up requests, as needed.

Identifies and evaluates potential red flags and works in collaboration with practitioner(s) to document the issue and practitioner response.

Advises MercyCare Medical Director of questionable information received and any issues identified during processes.

Manages sanctions and complaints on a monthly basis and reports any findings to the Medical Director, Director of Network Development, the Medical Staff Office, and the credentialing committee

Makes appropriate and accurate entries into applicable systems to activate the practitioner and ensure practitioner inclusion in rosters, directories, and reports.

Manages all credentials files to ensure that all correspondence is accurately filed; is knowledgeable and current in regards to process.

Meets and maintains productivity standards as outlined by the department.

Manages meetings for the credentialing committee, sends out notices, drafts agenda, assembles meeting materials, drafts minutes and follow-up correspondence.

Maintains information in credentialing database and other systems.

Builds queries and reports in credentialing software.

Manages all aspects of the MercyCare provider/facility directory. Ensuring compliance with regulatory standards and NCQA standards.

Project management for implementation and upgrades of credentialing software

Participates in workgroups

Maintains current knowledge of NCQA standards for each year

Development and maintenance of all Standard Operating Procedures for credentialing

Attends webinars or continued education meetings

Participates in HEDIS, as applicable to credentialing.

Manages delegated audits on an as-needed basis

Assists in the Medicaid re-certification process on an annual basis to ensure compliance as it relates to credentialing

Assists providers in signing up for access to the MercyCare directory

Participates in annual review of the MercyCare Provider Manual. Works closely with the MercyCare Contracting department and provider management department to ensure all data is accurate

Manages surveys to providers to ensure most accurate cultural responsiveness is on file

Manages weekly, monthly, quarterly and annual reports and distributes information to appropriate departments in a timely manner

CULTURE OF EXCELLENCE BEHAVIOR EXPECTATIONS

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

EDUCATION & EXPERIENCE

Associate's degree and 1 year of healthcare credentialing experience preferred (healthcare facility, managed care setting, CVO, or medical staff office), OR a minimum of 2 years of experience in credentialing (preferred), OR a minimum of 3 years of experience in a business support area required.

CERTIFICATION/LICENSURE

None.

ADDITIONAL REQUIREMENTS

Passing the Driver's License Check and/or Credit Check (for those positions requiring).

Passing the WI Caregiver Background Check and/or IL Health Care Workers Background Check. Must be able to follow written/oral instructions.

OTHER SKILLS AND ABILITIES

Experience with credentialing accreditation by NCQA.

Demonstrated working knowledge of healthcare and credentialing industry, including medicolegal issues and laws, regulatory agencies, and other national standards preferred.

Understanding of professional telephone etiquette.

Able to work with minimal supervision and under pressure. Able to work well in individual and group environment.

Proactively prioritizes needs. Shows attention to detail.

Communicates clearly and concisely. Must have excellent interpersonal and written communication skills, including spelling, grammar and basic mathematical calculations.

Establishes and maintains long-term customer relationships by building trust and respect. Articulates knowledge and understanding or organizational policies, procedures, systems.

Demonstrates proficiency in Microsoft Office (Word, Excel, Access) and other applications, as required.

Demonstrates knowledge of credentialing software;

Maintains confidentiality of privileged information.

Knowledge of accepted practices related to primary source verification.

WORK ENVIRONMENT

The noise level in the work environment is usually quiet.

Occupational Exposure: Category C -No partners in the specified job classification have occupational exposure.

AGE OF PATIENTS SERVED

Non-Specific Task (N/A)

INFORMATION ACCESS

Partner may access patient care information needed to perform their job duties.

WORK CONTACT GROUP

All system partners including physicians, all customer groups including community, other healthcare professionals.

SPECIAL PHYSICAL DEMANDS

The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.

In order to perform the demands of this job, the employee may sit for long periods, exerting up to 10 pounds of force occasionally, walking and standing occasionally. The employee is required to frequently reach with hands and arms, finger, handle, talk and hear. Manual dexterity is required.

LEVEL OF SUPERVISION

Some independent judgement is required, but alternatives are limited by standard practices and procedures.

SUPERVISES

None.

PAY RANGE:

$21.85 - $34.96

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

Medical, Dental, Vision
Life & Disability Insurance
FSA/HSA Options
Generous, accruing paid time off
Paid Parental and caregiver leave
Career advancement and educational opportunities
Tuition and certification reimbursement
Certification Reimbursement
Well-being Programs
Employee Discounts
On-Demand Pay
Financial Education
Annual recognition/awards events
Partner appreciation days
Family entertainment/attractions discount
Community service/improvement opportunities

At Mercyhealth, we don't simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including: