Under indirect supervision, provides administrative & technical services for credentialing & recredentialing function. Represents all affiliated community practitioners during monthly Credentialing/Peer Review Committee meetings. Works closely w/ Provider Relations, Chief of Risk Management, Chiefs of Services, Member Services. QAIR Peer Review, community hospitals & practitioners groups, as well as all affiliated community practitioners to achieve credentialing function. Works closely in team-based department w/ Credentialing Services personnel to complete all compliance & time requirements necessary to maintain Organization's accreditation. Supports compliance & Principles of Responsibility. Maintains confidentiality. Protects organizational assets. Exhibits ethics & integrity. Adheres to applicable federal & state laws & regulations, accreditation & licensing requirements, policies & procedures. Reports &/or resolves issues of non-compliance.
Essential Functions:
- Provides administrative & technical expertise to credentialing services functions. Completes credentialing & recredentialing application process of all internal & affiliated community practitioners. Processes request, investigation, verification, tracking & follow up of primary responses from various sources [e.g., Hawaii Medical Board, National Practitioner Data Bank (HIPDB), Office of the Inspector General (OIG) for Medicare/Medicaid sanctions, American Board of Medical Specialties (ABMS), Specialty-specific boards, National Technical Information Services (NTIS), Hawaii Board of Chiropractors, Hawaii Board of Podiatry, Hawaii Board of Nursing, Hawaii Board of Social Workers, Hawaii Board of Psychology, all hospital affiliations, all medical &/or professional education, work history, professional references]
- Identifies, investigates, reports, tracks, & follows-up on any potentially adverse information received from credentialing sources according to established guidelines & procedures w/ goal of reducing any risk management issues
- Reviews files for any 'red flag' issues. Routes accordingly
- Obtains & maintains appropriate knowledge of company policy & procedures, accreditation standards, state & federal regulations, guidelines, procedures & laws required in credentialing process
- Populates, updates, & maintains credentialing software & filing systems. Assists w/ Requests for Proposals or any requested reports as necessary & in collaboration w/ supervisor or other Credentialing Services staff
- Maintains practitioner files annually
- Ensures medical licenses, DEA certificates & malpractice certificates are current at all times for affiliated community practitioners
- Provides back up at new employee orientation to newly employed practitioners on behalf of Credentialing Specialist (Internal)
- Works w/ designated QAIR Peer Review & Member Services personnel prior to each Credentialing/Peer Review meeting & on an on-going basis to coordinate Peer Review information into credentialing & recredentialing files as necessary
- Works closely w/ Chief of Risk Management to identify & coordinate any risk management, substance abuse &/or malpractice issues
- Commits to improve professional growth & knowledge of job to maintain efficiency & effectiveness of credentialing function by participating in professional organizations &/or other organizations addressing credentialing, compliance &/or risk management activities
- Additional essential functions as listed in the complete job description
Qualifications:
Basic Qualifications:
- Two years of clerical or medical office experience
- Associate's degree in health care or technical field
- Knowledge of and experience with effective office procedures, including filing systems, electronic record systems, routing procedures, and business organization and practice
- Demonstrated knowledge of and skill in written communication, oral communication, interpersonal relations, adaptability (flexible work situations), influence (with physicians and senior executives), problem solving, project management, quality management, results orientation (meeting deadlines), and teamwork
- Demonstrated knowledge of and skill in word processing, spreadsheet, and database (credentialing/tracking system) PC applications
- Talking to co-workers, customers, outside vendors, and on the telephone
- Reading, writing, speaking, understanding English
- Training/giving and receiving instructions
- Mathematical ability, attention to detail (e.g., organization, prioritization, proofing), concentration, and alertness
Preferred Qualifications:
- Experience working with physicians and/or senior executives
- Bachelor's degree in health care or technical field
- Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator (CMSC) by the National Association Medical Staff Services (NAMSS)
- Knowledge of medical terminology
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.