Job: Credentialing Specialist - Quality Management

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Jobing Description

Category: Administrative/Clerical
Facility: Phoenix Health Plan/Abrazo Advantage Health Plan
Department: Quality Management
Schedule: Full Time
Shift: Day Shift
Hours: 80
Job Details:Responsible for coordinating the centralized provider application process for all product lines. Creates and maintains provider applications and tracks files through the re/credentialing process. Analyzes processes and solves problems to assure completion of the credentialing and recredentialing according to established standards and timelines.

Primary responsibilities include:

Log and track the provider applications and re/credentialing processes.
Performs primary source verification and gathers appropriate information to complete credentialing and recredentialing within required timelines.
Analyze the re/credentialing status of plan providers to assess re/credentialing timelines, and send recredentialing applications according to established schedules.
Monitor receipt, as well as follow up until all documents are received and complete.
Enter application data and re/credentialing information into the credentialing database. Monitor the database on an ongoing basis to maintain integrity of data, identify, and resolve data issues contained therein.
Interface with internal and external customers, providers and outside sources, such as the National Practitioner Data Bank and licensing boards, to ensure appropriate information in maintained and update
Create systems to monitor and track status of applications and maintenance of re/credentialing files, monitor primary source verification documents.
Conduct file comparison to established criteria and resolve problems on an ongoing basis to ensure re/credentialing file compliance with company policy and State and CMS standards.
Analyze progress of files through the credentialing and recredentialing process and provide ongoing and retrospective reports to Network Management and others as applicable.
Notify network management when a credentialing file is complete, and assure all information is forwarded to all users of information in a timely manner.
Conduct assessments of the organization provider database. Maintain, log, monitor and communicate status of re/credentialing files of organization providers to Network.
Communicates with Providers via verbal or written provider regarding application/reapplication discrepancies, and other credentialing issues.
Ensures all completed files are entered and reviewed by the credentialing committee for consideration and enters committee decisions into the database in a timely manner.
Documents in software system member-specific interactions using documented processes accurately and timely.

Special Skills: Analytical and problem solving skills effective written and oral communication skills.

Minimum Requirements: High School Graduate required. Database management and computer knowledge/experience required.

Preferred Qualifications: Completion of some college courses preferred. Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator (CMSC) or equivalent experience (3 yrs +) preferred.

Skills / Requirements

See Above