| General Position Summary: The Coordinator is responsible for all aspects of the credentialing, recredentialing, and privileging process for all medical staff and allied health professional staff (health care providers) who provide patient care at facilities associated with Summit Healthcare Association. This includes ensuring health care providers are credentialed, appointed, and recredentialed with health plans. The Coordinator maintains up-to-date data for each health care provider in credentialing database(s) and online systems. The Coordinator serves as an essential link and resource between senior management and medical staff to coordinate the operational processes and ongoing credentialing, privileging, and medical staff governance functions of the associated facilities of Summit Healthcare Association. Responsible for review, analysis and follow up of credentialing and privileging applications, maintaining strict confidentiality, and ensuring compliance with organizational policies and accrediting and regulatory agencies. Essential Functions / Major Responsibilities: - Manages, coordinates, and monitors all aspects of the initial, provisional, reappointment, and privileging process and health plan credentialing for health care providers to ensure accurate and timely credentialing in compliance with the Medical Staff’s Bylaws and associated policies, health plan policies, and regulatory agency requirements, and in conformity with the Medical Staff Services Office policies and procedures.
- Identifies issues that require additional investigation and/or follow-up.
- Successfully implements the entire enrollment and health plan credentialing and recredentialing process for the organization (practitioners and entities). Coordinator must maintain timelines on enrollment/credentialing schedules, communicate with practitioners and other departments to update information as needed, clarify carrier information requirements, and maintain and update health plan rosters as requested, maintaining a strict level of confidentiality for all matters pertaining to health care provider credentials.
- Process other credentialing requests, as assigned, in accordance with established policies and procedures.
- Monitor and maintain health care provider and health plan credentialing expirables.
- Prepares summary reports of credentialing/privileging recommendations and ensures flow of information and action items for medical staff committees.
- Coordinates credentialing end-of-committee processes to ensure notification of health care providers, departments, and databases.
- Assists in coordination, tracking and monitoring of the OPPE and FPPE process ensuring compliance with regulatory standards and Medical Staff policies.
- Updates and distributes rosters and provider contact lists.
- Maintains confidential credentials files and electronic medical staff database.
- Responds to correspondence both internally and externally.
- Interprets and explains federal, state, local, and government/insurance agency regulations and guidelines, as well as Medical Staff Bylaws, rules and regulations, policies and procedures.
- Advises health care providers, management, and administrators on compliance issues as appropriate.
- Ensures compliance with State and Federal requirements and Accreditation standards.
- Generates queries and reports from provider database.
- Updates all PLIID (Practitioner, Location, Insurance ID) entries (i.e. practitioner and PTAN numbers) once health care provider enrollment process is completed.
- Establish professional relationship with health plan contacts to ensure information is being updated correctly and in a timely manner.
- Schedules, coordinates, prepares agendas, takes minutes, and provides follow up for medical staff committees as outlined in the Medical Staff Bylaws and associated documents.
- Assist in on-boarding and/or orientation of new health care providers according to established policies and procedures.
Secondary Functions: - Cross-trains with other Coordinators in department providing coverage/assistance as needed.
- Responsible for security and maintenance of all credentials files.
- Participates in departmental and hospitalwide informational meetings and inservices, including staff meetings, hospitalwide forums, and seminars.
- Continuously evaluates, proposes, and implements medical staff services procedures to standardize and ensure for accuracy and completeness.
- Works cooperatively with others for Medical Staff Development and Recruitment.
- Assists with monitoring and revising credentialing and privileging forms as needed.
- Reviews department and hospital-wide policies and procedures annually.
- Provides back-up services for creating, maintaining, and distributing the On-Call Schedule.
- Participates in ongoing education to stay abreast of federal, state, local, and government/insurance agency regulations and guidelines.
- All other duties as assigned.
Job Scope: This job involves: - Recurring work situations with occasional variations from the norm.
- A high degree of complexity and confidentiality.
- Typical operation from established and well-known procedures;
- Assist with developing new policies, processes, practices, programs, etc.
- Performance under limited supervision.
Interpersonal Contacts: Contacts: - Are normally made with others both inside and outside the system.
- Are usually made with own department as well as other departments or locations.
- Frequently contain confidential/sensitive information necessitating discretion at all times.
- Are made via telephone, e-mail, other electronic modalities, and face-to-face interaction.
- Are normally with physicians, other practitioners, health plans, staff and external verification sources.
Specific Job Skills & Mental Activities: This position requires operational knowledge of all equipment including: fax, printers, scanners, copy machine, binding machine, phone systems, overhead projector, and computer programs (including MDStaff, BoardEffect, MS Office, e-mail, internet, and all Hospital Information Systems). This employee must be service oriented and have excellent customer service skills, written and oral communication skills, computer skills, organizational skills, multitasking skills, professional interpersonal skills, time management skills, the ability to prioritize work, and telephone etiquette. This position requires knowledge of: medical and health plan credentialing and privileging procedures and standards; related accreditation and certification requirements; policies, regulations and bylaws and the legal environment within which they operate; ability to analyze, interpret, and draw inferences from research findings, and prepare reports; informational research skills; and the ability to use independent judgment and to manage and impart confidential information. Must be able to read, write, speak, and understand English. As an on-site employee, must be able to work in a shared workspace environment. Although on-site is preferred, remote work may be considered depending on state of residence. |
