Credentialing Specialist

Position Overview: Responsible for credentialing and recredentialing practitioners and facilities in accordance with PacificSource policies and procedures, ensuring compliance with National Committee for Quality Assurance (NCQA) standards and state and federal regulatory bodies. Participate in the development and implementation of credentialing policies and procedures to ensure timely, accurate credentialing of medical practitioners and facilities affiliated with PacificSource. Responsible for the ongoing maintenance of files, preparation of files for credentialing committee, as well as electronic database input and management. Communicate directly with practitioners and facilities on credentialing issues and medical practice information.

Responsibilities:
Essential Responsibilities:

Perform credentialing activities related to credentialing operations. Organize project work, maintain inter-departmental contacts on credentialing issues, and maintain credentialing status reports.

Responsible for conducting primary source verification on applicants which may include but not limited to, request, investigation, verification, tracking, and follow-up of primary responses from all required sources as required by the PacificSource credentialing policies and procedures.

Review monthly reports to assure all practitioners and facilities complete recredentialing in accordance with the assigned target date and that no practitioners or facilities are dropped from the recredentialing schedule.

Perform internal audits of practitioner and facility credentialing and recredentialing files to ensure accurate and high quality performance standards and PRISM measures are met. Report any quality deficiencies to the Credentialing Team Lead.

Act as liaison to contracted practitioners and facilities to assist with credentialing issues and ensure that demographic information is received and entered in the system correctly. Perform monthly audits of practitioner and facility data in credentialing database to ensure information is accurate and current.

Identify and prepare reports for the Chief Medical Officer and/or Credentialing Committee on any practitioner/facility concerns, problems, or adverse actions.

Process and respond to member complaints received regarding participating practitioners and facilities concerning quality of care and report to the Chief Medical Officer and Credentialing Committee. Maintain and track complaints in the practitioner/facility file and complaint log.

Maintain collaborative relationships and act as a liaison for PacificSource with internal, and interdepartmental staff, as well as external customers.

Supporting Responsibilities:

Maintain familiarity with PacificSource credentialing policies and procedures, National Practitioner Data Bank (NPDB) reporting requirements, State Medical Board policies, NCQA credentialing standards, and state and federal regulatory credentialing requirements. Attend workshops and seminars to increase and maintain knowledge as necessary.

Participate in the training and orientation of new hires.

Meet department and company performance and attendance expectations.

Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

Perform other duties as assigned.

Qualifications:
Work Experience: Minimum three years credentialing experience in the credentialing field and/or equivalent experience.

Education, Certificates, Licenses: High School Diploma or equivalent required. NAMSS Certified Provider Credentialing Specialist Certification (CPCS) preferred.

Knowledge: Effective written and verbal communication skills. Must be highly organized and possess strong interpersonal skills. Knowledge of NCQA credentialing standards as well as state and regulatory credentialing requirements. Knowledge of policy and procedure development. Knowledge of requirements and functions of the Credentialing Committee and how it contributes to the credentialing functions. Maintain regular contact with PacificSource Provider Network Management Department to update current practitioner information. Computer skills, including word processing, spreadsheet, database applications and medical terminology.

Competencies

Our Values

Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards

We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for our customers’ experience.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internal and external.
We encourage creativity, innovation, and the pursuit of excellence.

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.