Purpose
The Credentialing Specialist is responsible for all aspects of the credentialing, recredentialing and privileging processes for all medical providers who provide patient care at Wilmington Health and the Wilmington Health Ambulatory Surgery Center. Responsible for ensuring providers are credentialed, appointed, and privileged with health plans and hospitals. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.
Essential Duties and Responsibilities
- Compiles and maintains current and accurate data for all providers.
- Completes provider credentialing and recredentialing applications; monitors applications and follows-up as needed.
- Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
- Maintains knowledge of current health plan and agency requirements for credentialing providers.
- Sets up and maintains provider information in credentialing database.
- Tracks license and certification expirations for all providers and clinical personnel to ensure timely renewals.
- Ensures practice addresses are current with health plans, agencies and other entities.
- Processes applications for appointment and reappointment of privileges to ASC.
- Tracks license, DEA and professional liability expirations for appointed ASC providers and clinical personnel.
- Maintains ASC appointment files, and information in credentialing database.
- Audits health plan directories for current and accurate provider information.
Other- Compliance, HIPAA and Security
- Employees acknowledge that compliance with Wilmington Health’s HIPAA, Security and Compliance Plan policies and procedures as well as all other Wilmington Health policies and procedures is a condition of employment and that any violation will result in sanctions up to and including termination based on the type and severity of the violation.
- Maintains confidentiality of provider and clinical personnel information.
- Extensive and frequent verbal and written communications with Clinicians, Medical Staff Offices, state licensing boards, professional references and internal company staff, requiring professionalism and tact, to obtain or provide all needed information quickly in order to expedite the credentialing of providers.
- Provides excellent customer service in accordance with Wilmington Health’s customer service standards to all internal and external parties.
- Ensures proper interpretation of and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statutes and laws relating to credentialing. Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow-up. Communicates issues to management in a timely manner as appropriate.
- Achieves compliance with Credentialing Department metrics and performance standards by adhering to the Credentialing process and documenting accurately in company database(s). Accurately maintains systems database(s) to track, follow-up and disseminate status of credentialing, hospital privilege and payer enrollment to other departments in a timely manner. May be involved in generating and managing various reports for management, implementing best practices and working on projects as assigned.
- Attend and participate in required meetings; participating in developing and implementing company-wide goals; participates in problem-solving and decision making; positively supports and adheres to management decisions, being flexible and adaptable to change, establishing trust and respect for other team members and completing training as required.
Other Duties
- Responsible for other duties as assigned
Minimum Qualifications
- Two or more years of managed care plan, NCQA or Joint Commission credentialing experience/working knowledge
- Ability to use independent judgment to manage and impart confidential information; works independently, is self-directed and effective in a team, high-paced environment
- Ability to organize, prioritize, coordinate and follow thru on multiple activities and tasks in a timely manner
- Excellent customer service and organizational skills
- The ability to handle high volumes of files under tight deadlines and set priorities
- Strong teamwork orientation regarding resolution of issues
- Demonstrated proficiency in use of Microsoft Office applications; Word, Excel, Access, Outlook; and conducting research using various websites
- Excellent verbal and written communication skills are essential. Able to communicate and present information to a wide variety of parties effectively
Required Skills
Credentialing Specialist Competencies
General
- Professionalism/Integrity/Responsibility
- Dependability/Punctuality
- Interpersonal Relationships/Communication
- Judgment/Decision Making/Problem Solving
- Organizational Skills/Time Management
ADA Physical Demands
Rarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)
Physical Demand
Frequency
Standing
Frequently
Sitting
Continuously
Walking
Frequently
Kneeling/Crouching
Rarely
Lifting
Rarely
Required Experience