Coordinator Credentialing Sr
Posted on: November 22, 2021
Your career starts now. We're looking for the next generation of
health care leaders.At AmeriHealth Caritas, we're passionate about
helping people get care, stay well and build healthy communities.
As one of the nation's leaders in health care solutions, we offer
our associates the opportunity to impact the lives of millions of
people through our national footprint of products, services and
award-winning programs. AmeriHealth Caritas is seeking talented,
passionate individuals to join our team. Together we can build
healthier communities. If you want to make a difference, we'd like
to hear from you.Headquartered in Philadelphia, AmeriHealth Caritas
is a mission-driven organization with more than 30 years of
experience. We deliver comprehensive, outcomes-driven care to those
who need it most. We offer integrated managed care products,
pharmaceutical benefit management and specialty pharmacy services,
behavioral health services, and other administrative services.
Discover more about us at
www.amerihealthcaritas.com.Responsibilities:Under the supervision
of the Manager of Credentialing, the Credentialing Coordinator is
responsible for initiating, processing, and completing the
credentialing and re-credentialing functions for KMHP/AMHP
practitioners and providers. The Senior Credentialing Coordinator
is further responsible for training in Primary Source Verification,
provider research as well as credentialing and re-credentialing of
providers identified as high risk categories. The Credentialing
Coordinator responsibilities include maintaining knowledge of NCQA
and DPW regulations, maintaining productivity and accuracy
standards associated with the credentialing functions.
- Process provider applications in an accurate (with 95%
accuracy) timely manner within the 180-day verification time limit.
Review applications for completeness of the application and
supporting credentials, including current status of all
- Performs Primary Source Verification training to new
- Presents on credentialing topics during monthly training and
- Assumes the major responsibility for the credentialing and
re-credentialing of high-risk providers with complicated sanction
histories, disciplinary actions, providers who do not meet the
credentialing requirements, and providers with malpractice
histories that exceed the cost of credentialing and
- Documents the date of receipt of applications and the initials
of the coordinator assigned to process the
credentialing/re-credentialing on provider applications and
- Enter data of all initial credentialing and re-credentialing
application into the Visual Cactus credentialing database.
- Request and obtain all missing information and/or updated
information related to the application or source documents.
- Establish a credentialing file for all new applicants.
- Incorporate updated information and provider profile
information in the re-credentialing file.
- Perform primary source verification of all supporting provider
credentials through telephone, fax, and online systems within the
180-day verification time limit.
- Obtain primary source verification of licensure, education and
training, and specialty board certification via telephone, fax or
- Query online databases for malpractice and sanction
- Communicate clearly and effectively when requesting
verification of hospital privileges.
- Obtain provider performance reports for the credentialing and
- Site visit scores (credentialing)
- Site visit and medical record review scores
- Transfer notes (re-credentialing)
- Member complaints (re-credentialing)
- Obligation reports (re-credentialing)
- Quality of care issues (re-credentialing)
- Provider improvement activities (re-credentialing)
- Submit completed credentialing and re-credentialing files to
the Manager of Credentialing for review determining the following:
- Status of the file as clean or problem for further review
- Flag all problems in the practitioner file for Medical Director
- Follow-up on issues generated from Medical Director or
credentialing committee reviews.
- Participates in provider research projects as assigned by the
- Provide accurate and timely response to inquiries regarding
provider status as it relates to the credentialing and
- Manages large hospital provider groups for credentialing needs
such as report reconciliation for outstanding providers,
identification of provider requiring credentialing, and education
to the credentialing and re-credentialing process.
- Perform data entry corrections resulting from Visual Cactus
system data audit reports.
- Undergo reliability audits on credentialing and
re-credentialing files using the NCQA audit tool.
- Submit a monthly productivity report to the Manager of
- Participates in Provider Network and Quality Management
workgroups, and performs workgroup assignments.
- Adhere to established guidelines as defined by
- Report to work each day at assigned time;
- Maintain professional appearance as defined by Company
- Adhere to established guidelines regarding absenteeism as
defined by Company Policy;
- Cooperate with manager to adjust work schedule to accommodate
- Maintain a courteous, friendly and professional attitude
towards co-workers and customers;
- Demonstrate competence and good judgment in daily planning to
identify and complete priority responsibilities on time.
- Perform other duties as assigned by Department Manager
- Demonstrate flexibility and willingness to assist other
Department personnel as necessary to meet shifting priorities
- Demonstrate enthusiasm, dedication and commitment to Department
goals and objectives
- Contribute ideas and suggestions to improve department
- Accept other duties as a challenge and opportunity to
- Pursue opportunities for personal development, knowledge and
increased responsibility.Education/ Experience:
- Associate's Degree related field.
- CPCS or CMSA certification or equivalent Credentialing
- Knowledge of basic Health Care, Managed Care principles, and
Medical terminology preferred.
- 5 to 10 yeras credentialing functions with the plan's
Credentialing Department, or Medical Staff coordination.Other
- Proficiency with Microsoft Office applications (Excel, Word,
- Proficiency in use of related applications/internal systems to
collect information necessary to complete principal
accountabilities (e.g., Healthcare System, MACESS/IMAX,
- Effective verbal and written communication skills.
- Ability to plan own schedule, set priorities and work
independently in accomplishing work assignments on time.Back
Keywords: Amerihealth, Philadelphia , Coordinator Credentialing Sr, Other , Philadelphia, Pennsylvania
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