In collaboration with provider’s and staff across all disciplines and departments is responsible for the initial credentialing, re-credentialing, and privileging process for providers performing medical services at CommUnityCare Health Centers.

Essential Duties
• Facilitate requests for initial, re-credentialing and additional privilege applications in accordance with Credentialing and Privileging Policy/Process.
• Apply the credentials evaluation process uniformly to all initial, re-credentialing and additional privilege applications to ensure compliance with Credentialing and Privileging Policy/Process.
• Process each initial, re-credentialing application received in accordance with Credentialing and Privileging Policy/Process.
• Compile and analyze any available internal data and information for an assessment of qualifications and competencies for each re-credentialing application.
o Compile internal data on provider’s volume
o Compile internal information related to focused or ongoing professional practice evaluations (FPPE/OPPE), performance improvement, utilization patterns, peer review, or performance information, as assigned.
• Facilitate review, assessment, and authenticated documentation for an evaluation of each application and request for clinical privileges by the Medical Director, as required.
• Facilitate review, assessment and recommendations for each application and request for clinical privileges by the Medical Director and the Credentials Committee.
• Summarize and prepare credentialing information, including flagged concerns, for the Credentials Committee and board’s review and decisions.
• Actively manage provider’s expiring credentials in accordance with Credentialing and Privileging Policy/Process.
• Update the Access system to reflect all board actions on a provider’s initial, re-credentialing and additional privilege requests, including resignations, terminations, LOAs, denials, terminations, or withdrawals in accordance with Credentialing and Privileging Policy/Process.
• Manage and archive files according to Credentialing and Privileging Policy and Process.
Privileging
• Assist with development of eligibility criteria for each clinical privilege.
• Assist/Verify the review of requests for clinical privileges using the approved eligibility criteria.
• Assess the applicability and appropriateness of clinical privileges for each specialty
• Maintain all up-to date-privilege content via the List of Abilities.
• Coordinate access of Credentialed and Privileged medical staff information as needed
• Assist with facilitating of any required regulatory agency reporting of adverse actions taken against a provider’s medical staff membership or clinical privileges, as directed by facility leaders.
Performance Improvement/Peer Review
• Coordinate with Peer Review or designee to facilitate focused professional practice evaluation (FPPE), and any related evaluation at the conclusion of FPPE or period of review.
• Coordinate with Peer Review or designee to facilitate focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).
• Coordinate with Peer Review and Credentialed and Privileged medical Staff in the conduct of internal and external peer reviews, as applicable.
• Coordinate with Peer Review or designee the completion of a summary of FPPE, OPPE, and peer review results (e.g. performance profiles) for evaluation by medical staff leaders as part of the re-credentialing application process and/or ongoing.
• In collaboration with Peer Review, identify critical Credentialing and Privileging performance benchmarks, measure performance, and take action to improve when performance is not as desired or expected.

Risk Management
• Coordinate with the Medical Director, Peer Review, Operations and/or Risk Manager to review and evaluate an applicant’s claims history and NPDB or other reports regarding final settlements.
• Ensure timely and proper notification of the Medical Director, Peer Review, Operations, and/or Risk Manager regarding possible malpractice or other liability concerns.
• Coordinate all medical staff disciplinary actions (e.g., ad hoc investigations).
• Facilitate due process in accordance with the Peer Review Policy fair hearing and appeals policy as well as legal and regulatory requirements.
• Facilitate leadership review of occurrence reports, patient complaints, close call data, and other risk management information.
Information Management
• Be able to articulate policies, and distribution of credentialing, privileging, and peer review information, in accordance with confidentiality requirements and record retention policies.
• Respond to external requests for information in accordance with policy.
Other Job Responsibilities
• Ensure that all work is done in a timely and accurate manner.
• Ensure adherence to all credentialing policies and procedures.
• Maintain strong working relationships with providers, health plan staff, and other credentialing verification offices.
• Maintain knowledge of current requirements for credentialing providers.
• Maintain confidentiality and adhere to all HIPAA guidelines and regulations.
• Ensure all tasks duties comply with all regulatory and accreditation standards including The Joint Commission, the National Committee Quality Assurance (NCQA) guidelines, and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
• Develop and maintain favorable internal relationships, partnerships with co-workers.
• Ensure all actions, job performance, personal conduct and communications represent CommUnityCare in a highly professional manner at all times.
• Uphold and ensure compliance and attention to all company policies and procedures as well as the overall mission and values of the organization.
• Ensure all initial credentialing, recredentialing and privileging of the medical staff comply and maintain knowledge of current requirements with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
• Accurately enters providers demographics and information into the credentialing Access database
• Ensure accurate credentialing by maintaining and processing current credentialing documents in the credentialing database and in the specific credentialing electronic files as they are received from providers according to national standards
• Perform verifications for all providers and updates expiring documents
• Works within established credentialing timeframes and notifies manager and others as to status and barriers to ensure that all work is done in a timely and accurate manner.
• Ensure that all licensed providers are presented to the Credentialing Committee in a timely manner.
• Monitors expiration of credentials and privileges as directed and is responsible for frequent outreach to providers, and staff across all disciplines, including calls, and with reminder emails to the using the access database 90, 60, 30 and daily markers.
• Responsible for the monthly ongoing monitoring of licenses and sanctions.
• Establishes and maintains a positive job performance, personal conduct, and communications and close working relationships with internal and external clients and represents CommUnityCare in a highly professional manner at all times.
• Processes verification letters as directed, maintains database
• Prepares reports and data to support department and organization goals.
• Prepare documentation for presentation to the credentialing committee on a monthly basis
• Prepare and send provider approval packets following credentialing committee decision
• Participates in staff meetings and recommends new approaches, policies and procedures to effect continual improvement in efficiency of the department and services performed.
• Uphold and ensure compliance, confidentiality and adhere to all HIPAA guidelines, pay attention and maintain a strict level of confidentiality for all company policies and procedures, departmental, and healthcare provider information as well as the overall mission and values of the organization
• Performs other related duties as assigned

Knowledge/Skills/Abilities:

• Organization – proactively prioritizes needs and effectively manages resources
• Communication – communicates clearly and concisely, demonstrates advanced understanding of medical terminology
• Analytical skills – demonstrates ability to critically evaluate and appropriately act upon complex clinical and technical information
• Leadership – guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services
• Customer orientation – establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
• Tactical execution – oversees the development, deployment, and direction of complex programs and processes
• Policies & Procedures – articulates knowledge and understanding of organizational policies, procedures, and systems
• PC Skills – demonstrates proficiency in Microsoft Office (Excel, Access, Word) applications, and others as required
• Medical staff services technical skills – extensive knowledge of credentialing, privileging, peer review, and all other aspects of medical staff services

MINIMUM EDUCATION: High School Diploma
PREFERRED EDUCATION: Bachelor’s Degree in Business Administration, Healthcare Administration or related field
MINIMUM EXPERIENCE: 3 years’ experience in a credentialing and privileging role with knowledge of ambulatory, managed care, and hospital initial and re-credentialing processes, and strong knowledge of NCQA, JC, HRSA, URAC, CMS, and TDI guidelines.
PREFERRED EXPERIENCE: 5 years’ experience in a credentialing and privileging role with knowledge of ambulatory, managed care, and hospital initial and re-credentialing processes, and strong knowledge of NCQA, JC, HRSA, URAC, CMS, and TDI guidelines.
REQUIRED CERTIFICATIONS/LICENSURE:
PREFERRED CERTIFICATIONS/LICENSURE: Certified Professional Credentialing Specialist, (CPCS) or in process of certification