Job Description

Receives direction and prioritization from Credentialing Director to coordinate the daily activities of the Credentialing Coordinators and Credentialing Clerks.  Ensures compliance with the HS1 Credentialing Program Description,  accreditation  standards, State/Commonwealth/Federal regulations and all HS1 affiliate and subsidiaries contracted clients requirements. Actively assists the Credentialing Director to ensure the success of the credentialing operations to meet HS1’s goals for ensuring a quality provider delivery system that provides  quality  care to contracted Health Plan’s members.

Essential Functions & Responsibilities

·         Responsible for the efficiency, effectiveness and prioritization of the department’s daily credentialing activities and coordinates with Credentialing Coordinators and Credentialing Clerks.

·         Ensures daily compliance with staff job descriptions and intra departmental coordination of activities.

·         Reports all areas of concern and/or non-compliance to Credentialing Director for recommendations and/or determinations.

·         Assists with HR and payroll activities.

·         Coordinates with applicable vendor to ensure timely receipt of work products.

·         Ensure compliance with existing Credentialing Program Descriptions/Work Plans, policies/procedures/processes and notify Director of non-compliance and/or revisions based on current practices.

·         Utilizes all applicable Credentialing Reports for timely initial and re-credentialing indicators, current status, expired credentials, etc. and coordinates with Network Management.

·         Reviews reports for accuracy and to identify areas for improvement or revisions.

·         Monitors compliance with performance of the Expired Credentials Report.

·         Reviews and responds daily to the Call Log.

·         Participates with Director for Credentialing Committee preparation:

o   Provides 2^nd level review of provider files

o   Contributes to the Credentialing Committee agenda

o   Ensures that all “adverse” files are reviewed by Medical Director and/or CMO

o   Confirms peer attendance for a panel

o   Arranges dinner and payment

·         Serves as Facilitator of Credentialing Committee meeting, as needed.

·         Performs ongoing and as needed audits of Credentialing Coordinators data entry accuracy and provides additional training.

·         Assists Director in pre-delegation and ongoing on-site audits of provider files.

·         Maintains current Credentialing Training Manual and assists with documented training.

·         Provides credentialing training to new employees and as needed. 

·         Assists in ensuring  the accuracy of SharePoint -  Credentialing  approved documents.

·         Identifies topics for departmental QI/CR meetings and assists Director as needed.

·         Actively participates and supports the company’s overall Quality Assurance, Risk Management, Compliance and Cultural Competancy Programs.

·         Prepares and submits monthly and quarterly departmental reports to the Quality Assurance Committee as required.

·         Supports Credentialing Delegation activities with pre-delegation audits and continuous oversight monitoring for compliance.

·         Assists with evaluating resources needed to support all accreditation, regulatory and contracted clients requirements and new business development.

•            Acts as a resource for Credentialing staff

Required Education and Experience

·         AA Degree in related field and two (2) years credentialing experience. 

·         Or, five (5) years related credentialing experience and/or training; or equivalent combination of education and experience.