Position Summary As a key member of the Business Services Department, serves as a primary point of contact for all aspects of credentialing and re-credentialing for physicians, advanced practice providers and organizational providers. The Coordinator works to develop and maintain a streamlined, efficient, and automated process for credentialing and re-credentialing in compliance with contracted health plans and National Committee for Quality Assurance (NCQA) requirements and per organization’s policies and procedures. This position works closely with other Meritage staff (e.g., Contracting, Network Relations, Claims and Utilization Management Department) to ensure providers are added to the network in a timely manner.
Essential Job Functions • Maintains up-to-date data for each provider in computer database by ensuring timely review of licenses and certifications renewals. • Reviews and screens initial and recredentialing applications for completeness, accuracy, and compliance with federal, state, and local guidelines, policies, and industry standards. • Identifies and resolves discrepancies, time gaps and other issues that could delay completion of the credentialing process. • Query monthly reports for expirable information (e.g., licenses, DEA, & malpractice insurance) and update database with new information. • Communicates clearly with providers or their staff as needed to provide timely responses to requests for additional credentialing information or issues as they arise. • Prepares credentialing files for presentation at the Membership Committee; responsible for confirming the completeness of information and all documentation prior to presentation. • Prepares custom reports from the department database for uploads to CVO and VerifyComply. • Maintains all the credentialing documentation are up to health plan audit standards and coordinates with Director and/or manager health plans for annual credentialing audits. • Maintains confidentiality of provider information. • Models professional work standards and behaviors to maintain and strengthen a professional working atmosphere and strictest confidentiality within the department and with other Meritage internal and external customers and work partners. • Responsible for all aspects of credentialing/re-credentialing providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, tracking license and certification expiration for providers, and accurately loading/maintaining provider information into the Credentialing database.
• Accountable for work performed by self, works to develop and maintain trusting working relationships with others, and seeks to continuously learn from errors and experiences, as well as new developments in job specific administration and operational areas. • Consistently demonstrate behaviors, conduct and communications that support Meritage’s Practices and Values of Accountability, Diversity, Integrity and Respect for others, and will seek to influence these behaviors in others. • Continuously endeavors to “raise the bar” of performance and teamwork through a focus on Innovation, Collaboration, Equality and Compassion. • Performs other duties as assigned related to supporting the Credentialing Department and the overall Meritage organization.
Qualifications & Requirements • Bachelor’s degree in a healthcare, business, or related field of study; or equivalent combination of education and experience. • Minimum 2 years’ related work experience, with 1 year of current credentialing work experience, preferably in a managed care setting. • National Association Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist (CPCS) preferred. • Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation. • Knowledge of Internet resources and regulatory agencies such as Medical Board of California, Drug Enforcement Administration (DEA), National Practitioner Data Bank (NPDB), and Office of Inspector General (OIG), etc. • Working knowledge and experience with office-based computer equipment, systems and applications (e.g. MS Office Suite: Word, Excel, PowerPoint, Outlook, Teams, Adobe and Publisher). • Able to use independent judgment and to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications. • Strong written and verbal communications skills. • Excellent customer services skills with a demonstrated genuine and friendly demeanor. • Detail orientation with the ability to organize and prioritize work and manage multiple priorities with mature judgement. • Demonstrated ability to work and communicate efficiently and effectively with physicians and their staff on credentialing matters. • Ability to multi-task and meet deadlines and agreed upon deliverables. • Ability to problem solve and research and analyze data, discrepancies, and variances. • Ability to work independently with minimal supervision.
