Credentialing Specialist

Please note this role will be hybrid Remote Monday & Friday in office Tuesday-Thursday.

About GW MFA

MFA physicians provide comprehensive patient care, offering one practice for the whole person with 52 medical and surgical specialties. As members of the GW School of Medicine and Health Sciences faculty, MFA providers are teachers and mentors for medical students, residents, fellows, and researchers preserving the rich tradition of academics, research, and healing. In addition to maintaining a closely integrated alliance with The George Washington University and The George Washington University Hospital (GWUH) which is separately owned and operated by Universal Health Services (UHS), the GW MFA has active referring relationships with 12 area hospitals.

The GW MFA's leading healthcare presence in the DC metro region is complemented by a network of community-based practices in DC, Maryland, and Virginia. Given its geographic location in central NW Washington, DC, and proximity to more than 175 resident embassies, the MFA continues to evolve its international clinical outreach.

Position Summary

Perform day-to-day credentialing and re-credentialing activities for providers within the Credentialing Department. Performs payor enrollment and maintenance with payors on a regular basis. Maintain customer-focused relationships with MFA departmental contacts to ensure a smooth and efficient credentialing process.

Essential Duties and Responsibilities

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned.

Credentialing & Privileging - conduct and participate in credentialing and privileging activities (40%)

• Determine the practitioner's eligibility for membership/participation to ensure compliance with accreditation and regulatory standards.

• Distribute and track all credentialing application packets requested by MFA department contacts for prospective practitioners.

• Utilize the CAQH database to retrieve and analyze practitioner applications and supporting documentation for completeness according to accreditation and regulatory standards.

• Inform practitioner and MFA department contacts of the application status, and resolve pending issues, including the collection of additional information.

• Ensure compliance with accreditation and regulatory standards by processing initial and reappointment applications for eligible practitioners.

• Compile, evaluate, and present practitioner files for committee review to ensure compliance with accreditation and regulatory standards.

• Complete practitioners' enrollment applications into DC Medicaid, Maryland Medicaid, Virginia Medicaid, Medicare, and Tricare.

• Ensure the provider numbers for the governmental payors are loaded in the billing system to ensure the timely release of claims to the payors.

• Complete the revalidation/re-enrollment application into DC Medicaid, Maryland Medicaid, Virginia Medicaid, and Medicare for each practitioner every five years.

• Update the medical/professional licenses that are about to expire with DC Medicaid, Maryland Medicaid, and Virginia Medicaid.

• Work with the billing department to make sure rejections for credentialing-related reasons are addressed in a timely fashion and the charges are resubmitted for payment.

Primary Source Verification

• Conduct primary source verification activities (20%)

• Obtain and evaluate information from acceptable primary sources to ensure compliance with accreditation and regulatory standards.

• Identify, investigate, and report any discrepancies/adverse information obtained from practitioner applications, primary source verifications, or other sources.

• Verify and track expired documents utilizing acceptable verification sources to ensure compliance with accreditation and regulatory standards.

• Perform primary source verifications of licensure, board certification, DEA/CDS certification, education/training, Medicare/Medicaid sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB queries.

Compliance

• Comply with accreditation and regulatory standards (15%)

• Participate in the development, implementation, and ongoing assessment of bylaws, rules/regulations, and policies and procedures to ensure continuous compliance with accreditation and regulatory standards.

• Prepare documentation and participate in on-site audits from delegated credentialing entities to ensure compliance with accreditation and regulatory standards.

• Perform ongoing monitoring and evaluate practitioner sanctions, complaints, and adverse actions to ensure compliance with accreditation and regulatory standards.

Operations

• Support departmental/organizational operations (25%)

• Meet or exceed individual productivity metrics, quality, and timeliness standards as defined by department guidelines and current workload.

• Maintain credentialing database (MD-Staff); track collection of NPI, Medicare, Medicaid, DEA, CSC, and state licenses; update practitioner records as appropriate.

• Conduct follow-up with government payers to ensure application receipt and status of enrollment processing.

• Conduct research and resolve issues related to outstanding provider numbers from all governmental payors.

• Inform practitioners and stakeholders of credentialing decisions; send letters, reports, and systems updates in a timely manner.

• Coordinate committee meeting logistics, documentation preparation, and follow-up consistent with assigned credentialing-related activities.

• Coordinate collection of malpractice insurance certificates for new and current providers; serve as key liaison to MFA insurance administrator.

• Maintain adequate office supplies and complete orders for new supplies upon management approval.

• Perform miscellaneous duties as assigned including assisting Credentialing Manager with special projects.

Qualifications

Education

• A high school diploma or higher, or an equivalent combination of training and experience.

Experience

• A minimum of 2 years of experience in the healthcare industry.

• Prior experience in managed care and credentialing environment.

• Strong knowledge of NCQA credentialing standards and regulatory requirements.

• Professional experience using Microsoft Office applications including Excel and Word.

Physical Requirements

• Stand, bend, reach, and walk for long periods of time in an office setting.

• Must be able to occasionally lift, carry, push, or pull over 100 lbs. as part of the role.

• Regularly exposed to healthcare setting that may require personal protective equipment.

• Requires manual dexterity to operate computer keyboard, calculator, copier machine, and other equipment.