Credentialing Specialist-Pittsburg, KS


POSITION:  Credentialing and Contracting Specialist

DEPARTMENT: Corporate Compliance

REPORTS TO: Credentialing and Contracting Coordinator

DIRECT REPORTS: None

FLSA STATUS: Non-Exempt

CORE VALUES

The core values of Community Health Center of Southeast Kansas (CHC/SEK) are dignity and stewardship.  Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of the CHC/SEK’s resources.

GENERAL DESCRIPTION

This position is a part of the compliance/credentialing team.  This position assists with processing the credentials and privileges of all providers in order to verify accuracy and compliance with state and federal regulations and HRSA and FTCA deeming requirements.  This position is responsible to maintain database of practitioners' training, education, licensing.  This position supports the organization in submitting provider/facility applications to payers and is responsible for credentialing providers through third party payers.

ESSENTIAL DUTIES

  1. Knowledge of and adheres to CHC/SEK’s Credentialing policy and procedure and ensures process is completed timely.
  2. Completes research, reference and background verification on all providers prior to hiring.
  3. Verifies the professional credentials, references, claims history, fitness and professional review organization’s findings.
  4. Uses all available resources to verify provider applications, education, licensing and references following State and Federal guidelines for primary source verification.
  5. Communicates credentialing findings to supervisor.
  6. Creates and maintains database information for providers, including, but not limited to CAQH, KMAP, NPPES, NPI and other license, certification or professional membership that may be required to practice.
  7. Maintains accurate and complete credentialing file for all providers. Files are kept confidential and secure.
  8. Coordinates new provider information, such as DEA, license number and NPI, into the electronic health record system for billing purposes.
  9. Submits accurate and complete application information to payers to receive billing number to allow submission of claims for facilities and providers.
  10. Responsible for third party payer contracts are signed by all parties necessary to ensure plan enrollment.
  11. Completes EFT and ERA enrollment as part of the enrollment process to ensure electronic payments and claims submissions.
  12. Track progress of licensing requirements for providers as a part of payer enrollment.
  13. Provides accurate, complete and timely credentialing and privileging information for the re-credentialing process.
  14. Actively communicates with applicants, employment references and others as necessary to ensure timely completion of the credentialing and contracting process.
  15. Perform all duties, services and documentation in full compliance with CHC/SEK policies and procedures.
  16. Performs other duties as assigned.

QUALIFICATIONS

  1. High school diploma or equivalent required.
  2. Any combination of education and work experience that would likely provide the required knowledge and abilities is qualifying

KNOWLEDGE, SKILLS AND ABILITIES

  1. Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base.
  2. Communicates through appropriate channels. Use proper chain of command for patient complaints.
  3. Ability to handle emergency situations calmly and effectively.
  4. Must be computer literate and be proficient with the organization’s credentialing software system and the electronic medical record.
  5. Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization.
  6. Provide customer service in accordance to the organization’s mission.
  7. Be courteous and respectful when interacting with co-workers and others outside the organization.
  8. Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements.

WORKING CONDITIONS

While performing the duties of this Job, the employee is regularly required to sit; use hands and fingers to operate computer keyboard, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand.  The employee may occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus. Computer work is frequent. Good lighting and comfortable temperature of ventilation at all times