The Credentialing/ Licensure Specialist will be responsible for leading, coordinating, monitoring, and maintaining the credentialing and re-credentialing process. Facilitates all aspects of credentialing, including initial appointment, reappointment, expirables process, as well as clinical privileging for Registered Nurses, Allied Health Professionals, and all other providers. Ensures interpretation and compliance with the appropriate accrediting while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications.
Duties and Responsibilities
1. Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
2. Conducts thorough background investigation, research and primary source verification of all components of the application file.
3. Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
4. Prepares credentials file for completion and presentation to Account Manager ensuring file completion within time periods specified.
5. Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
6. Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to- day credentialing and privileging issues as they arise.
7. Assists with managed care delegated credentialing audits; conducts internal file audits.
8. Utilizes the credentialing database, optimizing efficiency, and performs query, report and document generation.
9. Monitors the initial, reappointment and expirables process for all medical staff, Allied Health Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (Joint Commission, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
10. Performs miscellaneous job-related duties as assigned.
Minimum Job Requirements
Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis. High school diploma or GED; at least 2 or more years of experience.
Knowledge, Skills and Abilities Required
- Ability to communicate effectively, both orally and in writing.
- Program planning and implementation skills.
- Knowledge of related accreditation and certification requirements.
- Knowledge of medical credentialing and privileging procedures and standards.
- Ability to analyze, interpret and draw inferences from research findings, and prepare reports.
- Working knowledge of clinical and/or hospital operations and procedures.
- Informational research skills.
- Ability to use independent judgment to manage and impart confidential information.
- Database management skills including querying, reporting, and document generation.
- Ability to make administrative/procedural decisions and judgments.
Working Conditions and Physical Effort
- No or very limited exposure to physical risk.
- No or very limited physical effort required.
- Work is normally performed in a typical interior/office work environment.