UM HEALTH PLAN-CREDENTIALING COORDINATOR

General Purpose of Job:

The Health Plan Credentialing Coordinator is responsible for assuring patient safety and ensuring the quality of the provider network through the rigorous credentialing and recredentialing process, conducted in accordance with regulatory agencies, accreditating bodies, Health Plan Bylaws and Health Plan policies and procedure for the initial, renewal and augmentation of applicants requesting membership into the Health Plans network. The Credentialing Coordinator supports the Credentialing Committees administrative functions. The Credentialing Coordinator develops objective, criteria-based credentialing criteria in conjunction with Health Plan Leadership and is responsible for the confidential collection, tracking, recording and monitoring of data required in the credentialing/recredentialing process and for accurate, clear, and concise external communication to providers and their staff. These processes include access to confidential on-line databases, on-line screen maintenance and updates to directories published by the Network Services Department. The Credentialing Coordinator maintains current knowledge of accreditation and regulatory standards governing the credentialing process, credentialing delegation and peer review activities and receives, manages and protects highly sensitive credentialing peer review information.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Maintains and applies expert knowledge of URAC and NCQA accreditation and regulatory standards related to credentialing, re-credentialing, credentialing delegation, peer review functions, provider directory and data maintenance requirements, as well as quality data reporting.
• Develop, build and maintain complex credentialing database and reports at the Health Plan level for internal and external customers
• Serves as an expert consultant to the Health Plan in Credentialing matters, including but not limited to credentialing, credentialing delegation, focused evaluation and ongoing professional/performance evaluation
• Oversee, verify, compile, manage and maintain the confidential information required for credentials of initial credentialing and ongoing recredentialing.
• Ensure all requirements are met with the primary source verification procedures as well as the credentialing standards developed and outlined in the Plan's credentialing policies and procedures.
• Ensures all new and existing applicants meet administrative criteria for participation with the Plan.
• Manage sensitive credentialing peer review information with a high degree of confidentiality and security
• Assess potential physician/practitioner problem areas for credentialing risks; gather and assess information from governmental agencies, e.g,, National Practitioner Data Bank; maintain skills for effective retrieval of information
• Assist Credentialing leadership in the determination of professional practice ongoing monitoring measures, provide baseline analysis of measures, coordinate education for performance improvement activities with appropriate areas
• Manage timelines for credentialing, recredentialing, department meetings, credentialing committee.
• Provide expertise for the revision of Health Plan Credentialing Bylaws and Credentialing Plan, manuals, rules and regulations for credentialing
• Participate in community-wide credentialing activities to promote efficiency of service and reduction of administrative redundancies
• Communicate with applicants related to ongoing status of application and notify applicants of missing information.
• * Reviews credentialing files with Manager and identifies areas of concern.
• Maintains provider directories with current and accurate information. Maintains current provider demographic and credentialing information in related database systems and requests assignment of participating provider numbers.
• Enters and audits credentialing and recredentialing information in the appropriate databases a for purposes of statistical reporting, HEDIS measures, and provider directories.
• Prepares and validates demographic changes and credentialing/recredentialing information for entry into the claims adjudication system.
• Reviews the provider queues of the claim processing system for required demographic updates, agreement additions/changes and/or provider loads necessary for appropriate claims adjudication.
• Supports leaders and associated Committee members, Department and Committee meetings.
• Oversee, verify, compile, manage, maintain data associated with resignation or terminations and other required practitioner data as part of delegated credentialing arrangements.
• Coordinate and facilitate new provider onboarding/orientation with Health Plan requirements directly or with other Health Plan staff