Assures that all clinicians' and potential clinicians' credentialing /recredentialing is in compliance with the standards of the National Committee of Quality Assurance (NCQA), HMO guidelines, and State and Federal Regulations. Enrolls employed clinicians with contracted insurance companies, adhering to/ maintaining necessary guidelines to preserve delegation standards.
Assembles, maintains, and distributes credentialing packets to appropriate source. Monitors the Credentialing Verification Organization's (CVO) duties to verify licensure, education/training, malpractice insurance, board certification, hospital privileges, etc.
Compiles and formulates a written summary report for presentation to Credentialing Committee, and approval signature by the Medical Director or Committee Chairperson. Works with the QM Specialist to prepare agenda and accurate, timely, complete minutes that include all actions taken in clinician approval process. Collects "fees" (e.g. credentialing fee, application fee, etc.) submitted by clinician and deposits in
the appropriate cost center. Notifies internal departments of approval/ start dates.
Compiles and maintains data for billing profiles, to assure timely billing for employed clinicians. Monitors clinician information from payors to establish or update BAR Physician Profiles for employed clinicians and communicates updates to appropriate others as necessary.
Reviews, approves, and updates internal marketing directories and payor directories for employed clinicians. Monitors and updates departmental "Effective Date" on-line report and the Sutter Connect Credentialing/Billing Log tracks, trends and develops solutions for reporting. Represents the
department at billing meetings.
Identifies and resolves clinician billing and payment issues related to clinician status. Updates and corrects employed clinician information for contracted payors Collaborates with the Contract Manager to resolve any subcontracted billing issues for employed clinicians.
Interacts with various departments and hospital staffs to ensure efficient and timely processing of credentialing files and applications. Acts as a liaison between various Medical Group Credentialing Committees and clinicians.
Investigates and reports concerns regarding Credentialing or Quality Assurance issues to the Quality Management Specialist(s) as appropriate.
Investigates and resolves licensing issues with the Medical Board of California. Investigates and resolves DEA certification issues with the Drug Enforcement Administration.
Monitors and updates all credentialing data and expirations (e.g. license, DEA, malpractice insurance, board certificates, etc.) and takes appropriate action as necessary. Monitors the CVO's assembly, tracking and distribution of reappoint/recredentialing packets. Reviews and evaluates the completeness of the reappointment packet and identifies problematic issues for review.
Prepares, submits and maintains clinician credentialing packets to contracted health plans. Organizes and prepares clinician credentialing files for third party payors' annual delegation audits.
Reviews monthly California Medical Board "Hot-Sheets Monthly Disciplinary Summary." Prepares, distributes and tracks governmental payor for employed clinicians. Distributes and tracks group supplier applications for durable medical equipment, prosthetics, orthotics, and supplies. Serves as an "authorized representative" for Medicare, Medi-Cal and DME supplier applications. Participates in clinician enrollment with subcontracted payors as instructed by contracting department.
Represents department at various Medical Group Credentials Committees. Disseminates approved policies and procedures to delegated payors.
MINIMUM POSITION REQUIREMENTS
Education, including Licensure/ Certification/ Registration
High School Diploma or equivalent. AA Degree or some college courses in business and/or a health related field is strongly recommended.
Knowledge of credentialing and recredentialing processes, NCQA standards and State and Federal credentialing requirements is required.
Knowledge of the managed care industry is required.
Knowledge of proper grammar usage and business writing skills is required. Must be familiar with medical terminology.
Experience communicating with physicians and health care professionals and experience handling and maintaining confidential information are required.
PC skills (MS Word, MS Excel, and MS Access) and proficiency regarding data entry skills are required. Problem solving skills and the ability to prioritize workloads are required.
Ability to work in a confidential environment and the ability to work independently with minimal supervision are required. Excellent oral communication, interpersonal and organizational skills are required. Excellent telephone etiquette and customer service skills are required. Requires accuracy, attention to detail, organization and prioritization skills, timeliness and computer skills, including word
processing, presentation and spreadsheets.