Credentialing Coordinator

Credentialing Coordinator

Corporate Services, Medical Affairs - Admin

3600 Civic Center Blvd.

Summary:

The Credentialing Coordinator is responsible for examining credentials and processing applications through to completeness for physicians and other health care practitioners applying to Penn Medicine for appointment, clinical privileges, and reappointment in accordance Penn Medicine Central Verification Organization (CVO) Policies and Procedures and applicable bylaws, Pennsylvania Department of Health, The Joint Commission (TJC), and the National Commission Quality Assurance (NCQA). The Credentialing Coordinator will maintain and verify all aspects of the application and verification process including communicating with providers, customers, and other stakeholders. Works in collaboration with support staff and other departments to ensure application and verification is completed within established CVO timeframes.

Responsibilities:

Access application for completeness and all required documentation. Examine information reported for missing data elements, timelines and time gaps. Identify as acceptable or adverse and report red flag when appropriate. Conduct follow-up with applicant on identified adverse elements. Research and investigate as necessary through to final resolution. Identify key issues in core credentials data.

Perform primary source verification of all required credentials data elements and direct inquiries to all required data banks, profiling providers, licensing/regulatory agencies, etc. in compliance with all accreditation (TJC, CMS, PA DOH, NCQA), federal, state and Penn Medicine requirements.

Examine and evaluate credentials information and results obtained by cross-referencing and comparing to information reported on application and curriculum vitae. Investigate discrepancies in data submittal related to applications, supporting documentation and formulate appropriate course of action. Examine for compliance with Penn Medicine staff qualifications and criteria. Investigate issues of concern, conduct follow up as needed and present findings accordingly. Report identified adverse information and unresolved questions to the Manager, Senior Manager, Client Medical Staff Office contact and Evaluation Team as appropriate.

Determine when investigation and credentials process is complete by comparing and contrasting file to requirements and verifying that all documentation meets standards.

Identify and flag time-sensitive items for reverification. Generate profile and reports.

Maintain accurate and current credentials database for all applicants. Record all credentials information immediately upon receipt. Monitor and track application status and credentials process. Maintain tracking documentation as per local standards to ensure continuity.

Provide first contact and professional customer service to applicants, vendors and credentialing staff within specified timeframes, required by the department. Communicate and document regularly to appraise of application status and/or any missing items.

Maintain current knowledge and understanding of Medical Staff Bylaws, Rules and Regulations, Medical Board Policies, CMS, DOH, TJC, and NCQA standards and other relevant materials in order to credential/re credential providers in accordance with standards set forth by these organizations.

Credentials:

NAMSS CPCS preferred.

Education or Equivalent Experience:

H.S. Diploma/GED required.

3+ years experience in credentialing in a managed care, hospital or related setting required.

Knowledge of medical credentialing and privilege procedures and standards; complete understanding of all regulatory standards and business rules required.