Provider Delegated Credentialing Analyst

Job Details

Job Description

• Responsible for the completion of initial, and recredentialing, applications for physicians nonphysician
• providers in accordance with JUP Delegated Credentialing procedures, NCQA
• guidelines and policies and procedures of delegated contracted health plans. Perform primary source verification of each physician's credentials in accordance with
• contractual requirements with delegated health plans, JUP's Delegated Credentialing Policies
• and Procedures, National Committee for Quality Assurance (NCQA) and DPW (Department of
• Public Welfare). Query the National Practitioner Database (NPDB), American Board of
• Medical Specialties (ABMS), Federation of State Medical Boards (FSMB), American Medical
• Association (AMA), American Osteopathic Association (AOA), and Educational Commission
• for Foreign Medical Graduates (ECFMG) to obtain authentic verification of credentials for each
• provider.
• - Contact institutions directly to verify medical training when it is not yet reported with the
• AMA/AOA
• - Routine review of OIG (Office of the Inspector General) sanction report and the PA, NJ, and
• DE disciplinary actions reports for all providers. Routine review of Medicheck of DPW
• (Department of Public Welfare) for Medicaid exclusions
• - Track all primary source verification charges for P-card for JUP Management approval
• - Review physician malpractice history, identifying any possible trends
• Revised 06/01/10
• - Prepare individual physician credentialing files in accordance with all established standards
• - Obtain all appropriate Department Chair approvals and necessary physician signatures on
• delegation files
• - Coordinate all necessary Practice Medical Record Audits for Delegation through TJU
• Compliance Office
• - Schedule, coordinate and perform required on-site Practice Site Visit Audits for Delegation
• with various Practice Administrators
• - Summarize all findings from Practice Medical Record Audits and Practice Site Visit Audits for
• presentation at JUP Credentialing Subcommittee; communicate and provide follow-up audits if
• warranted
• - Presentation of the delegated physician files at the monthly JUP Credentialing Subcommittee
• meeting, explaining any issues found that do not meet standard criteria
• - Preparation of the agenda, recording and distribution of Credentialing Subcommittee minutes
• - Run data queries in Access, compile large files in Excel, interpret and present data
• - Preparing and submitting lists of final approved physicians and ancillary providers to the
• delegated health plans.
• - Monthly and Quarterly reporting of all delegation decisions by JUP Credentialing
• Subcommittee to the health plans in accordance with contractual requirement to include all
• required credentials data elements for physicians initially credentialed, physicians
• recredentialed, physicians terminating from JUP, and results of any sanctions/exclusions
• queries found during primary source verification process.
• Schedule and provide all preparation necessary for delegated health plan audits of delegation
• files
• - Work closely with health plan health plan Quality Assurance Representatives during audits,
• and throughout the year, regarding JUP's credentialing polices and procedures for delegation
• - Maintain the integrity of the Delegation agreements by:
• o Monitoring established procedures, identifying and communicating any issues to JUP
• management
• o monitoring and communicating required NCQA updates to JUP management
• - Develop working relationships with health plan credentialing contacts to expedite credentialing
• and/or enrollment. Work directly with health plan contacts to update/change provider
• information and to resolve issues.
• Provider Enrollment
• * Provider Enrollment in health plans: Prepare initial and recredentialing health plan
• applications (or via on-line process as required by health plans) of non-delegated health plans
• for physicians and non-physician providers of Jefferson University Physicians (JUP) as well as
• other physicians and non-physician providers that contract with JUP Central Enrollments
• (JCE).
• * Monitor the method of enrollment for each health plan and notify manager when any change in
• requirements, forms, or processes are identified to maintain the timeliness and integrity of the
• credentialing process.
• * Internet-based Provider Data Management: Update and maintain data required for active
• participation in the health plans via universal internet based credentialing systems for each
• provider: PECOS (Medicare's Provider Enrollment, Chain and Operating System), CAQH
• (Council for Affordable Quality Healthcare) Universal Provider Datasource, and NPI (National
• Provider Identifier). Ensure that all physician and non-physician provider credentials (Medical
• Revised 06/01/10
• License, DEA, Board Certification, Malpractice Insurance coverage) are kept current in each
• database.
• * Maintain integrity of provider and practice information in JUP's physician Microsoft Access
• credentials database including but not limited to education, work history, training, licensure,
• board certifications, affiliations, individual and group provider numbers, social security number,
• etc. as required by health plans. Compile, review, scan and link confidential documents to the
• credentials database.
• * JUP clinical practice expansion: Work directly with Departmental managers to identify the
• appropriate process to establish new JUP practice locations with each health plan. Identify
• documents required for creating new assignment accounts with the health plans for multi-state
• enrollments such as Delaware and New Jersey, etc. Collect appropriate licensure and
• malpractice insurance face sheets for providers to be enrolled at each of the new locations.
• Coordinate with each health plan to expedite set up and eliminate claims reimbursement
• issues. Update all appropriate internet based credentialing systems (PECOS, CAQH, and
• NPI) with location and provider credentials.
• * Complete enrollment of non-physician providers including but not limited to CRNP's, PA's,
• CRNA's, CNM's, RD's in Medicare (and other health plans as accepted). Maintaining
• credentialing databases including PECOS, CAQH, and NPI.
• Identify, document and monitor the requirements to enroll non-physician providers with each
• health plan. Maintain internal tracking reports detailing credentials outstanding for enrollment,
• status of enrollment with the health plans, and recredentialing status as applicable.
• Maintain documentation of current collaborative agreements for non-physician providers.
• Interacts with co-workers, visitors, and other staff consistent with the core values of the University.

QUALIFICATIONS:

• BS in HealthCare Administration. Finance or business related area OR equivalent work experience.
• Minimum two years of experience working in a managed care setting
• Prior experience in credentialing and/or enrollment, with familiarity of NCQA
• Guidelines
• Prior experience in obtaining Primary Source Verification of credentials
• Ability to run queries in MS-Access, prepare large files in Excel, interpret and present
• data
• Strong organizational skills with a high attention to detail
• Ability to maintain highly confidential information
• Ability to handle multiple tasks and to be flexible regarding priorities and deadlines
• Excellent interpersonal and communication skills.
• Working knowledge of Microsoft Office products as well as full Adobe Acrobat
• Professional functionality (.PDF files)

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.