Credentialing Coordinator

General Summary

Maintains close communication with providers, practice managers and the medical staff office to ensure timely initial credentialing, recredentialing and reappointments through the different entities, Credentials Committee and Board of Directors Meetings.

Duties and Responsibilities

Essential Functions:

• Processes initial provider enrollment with payers, initial credentialing and recredentialing: - Creates, assembles and prepares application packet for providers to complete, reappointment applications for WellSpan Health entities and submits applications to payers. - Completes primary source verifying provider credentials per established policies and procedures. - Enters provider credentials and application requirements into Cactus, CAQH. - Initiates mandated queries, both federal and state, for all initial applicants and those due for recredentialing with the National Practitioner Data Bank. - Adheres to all policies and procedures regarding mandated queries and reporting mechanisms. - Maintains close communication with provider, practice managers, medical staff office, insurance reps, locum tenens agencies, office administrators to ensure timely credentialing through the different entities. - Reviews and conducts QA checks on the applications prior to medical director's review. - Reattests provider information every 120 days in CAQH. - Runs reports and complete Medicare and Medicaid revalidations for WellSpan Medical Group (WSMG) & Hospital Based providers. - Maintains confidentiality of provider information.
• Data Management - Follows up, receives and documents confirmations on all initial enrollment status and changes for health plan providers with which WellSpan participates. - Runs weekly Credentialing Update reports to IS Department for billing system update. - Runs expiring provider credentials reports, notifies practices and updates Cactus accordingly. - Assists with helping resolve claim issues by contacting applicable provider reps.
• Change letters - Creates and submits letters to update payers, Cactus, CAQH, NPI and other stakeholders of any changes and terms to provider data per 25 payer requirements.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Maintains professional growth and development.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree Preferred

Work Experience:

• 2 years Relevant experience. Required
• Hospital/physician office/insurance claims or credentialing experience. Preferred

Licenses:

• Certified Provider Credentialing Specialist Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Ability to multi-task and work independently by prioritizing work load.
• High level of organizational skills.
• Proficiency in data entry.
• Ability to handle interruptions such as phone calls, emails and meetings.
• Excellent computer skills.
• Excellent communication/interpersonal skills.