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Coordinator Credentialing Sr

Company: Amerihealth
Location: Philadelphia
Posted on: November 22, 2021

Job Description:

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 time-sensitive information.
  • Performs Primary Source Verification training to new coordinators.
  • Presents on credentialing topics during monthly training and educational sessions.
  • 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 re-credentialing providers.
  • Documents the date of receipt of applications and the initials of the coordinator assigned to process the credentialing/re-credentialing on provider applications and supporting documents.
  • 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 online.
  • Query online databases for malpractice and sanction reports.
  • Communicate clearly and effectively when requesting verification of hospital privileges.
  • Obtain provider performance reports for the credentialing and re-credentialing process.
    • Site visit scores (credentialing)
    • Site visit and medical record review scores (re-credentialing)
    • 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 Review.
      • Follow-up on issues generated from Medical Director or credentialing committee reviews.
      • Participates in provider research projects as assigned by the manager.
      • Provide accurate and timely response to inquiries regarding provider status as it relates to the credentialing and re-credentialing process.
      • 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 Credentialing.
      • Participates in Provider Network and Quality Management workgroups, and performs workgroup assignments.
      • Adhere to established guidelines as defined by Company/Department policy.
        • Report to work each day at assigned time;
        • Maintain professional appearance as defined by Company Policy;
        • Adhere to established guidelines regarding absenteeism as defined by Company Policy;
        • Cooperate with manager to adjust work schedule to accommodate Department needs;
        • 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 within Department.
        • Demonstrate enthusiasm, dedication and commitment to Department goals and objectives
        • Contribute ideas and suggestions to improve department functions.
        • Accept other duties as a challenge and opportunity to learn.
        • Pursue opportunities for personal development, knowledge and increased responsibility.Education/ Experience:
          • Associate's Degree related field.
          • CPCS or CMSA certification or equivalent Credentialing training.
          • 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 Skills:
            • Proficiency with Microsoft Office applications (Excel, Word, Access).
            • Proficiency in use of related applications/internal systems to collect information necessary to complete principal accountabilities (e.g., Healthcare System, MACESS/IMAX, Facets).
            • Effective verbal and written communication skills.
            • Ability to plan own schedule, set priorities and work independently in accomplishing work assignments on time.Back ShareApply Now

Keywords: Amerihealth, Philadelphia , Coordinator Credentialing Sr, Other , Philadelphia, Pennsylvania

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