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Covenant HealthCare US:MI:SAGINAW DAY SHIFT FULL TIME BENEFITED Summary:

The Credentialing and Delegation Specialist demonstrates excellent customer service performance in that his/her attitude and actions are always consistent with the standards contained in the Vision, Mission and Values of Covenant Health Care and the commitment to Extraordinary Care for Every Generation. The primary role of the Credentialing and Delegation Specialist is to complete, both, delegated and traditional credentialing files accurately, and efficiently.This position will be responsible for submitting initial credentialing applications, and all associated follow up on those applications. The Credentialing and Delegation Specialist will also be responsible for verifying the accuracy of all submitted credentialing information, and for creating, or auditing accurate Primary Source Verification (PSV) files for delegated credentialing through CAQH and maintain NCQA Credentialing/Recredentialing Accreditation.

Responsibilities:

Responsible for implementation and oversight of all activities related to physician credentialing, re-credentialing, and delegation. Responsible for compliance to delegation agreements. Responsible for the maintenance of Credentialing policies and procedures. Remain current with credentialing requirements mandated by external review agencies (e.g., NCQA, HFAP) and/or state and federal regulations. Collaborate with leader to modify delegation processes to ensure continued compliance with such requirements. Maintains detailed knowledge of NCQA and a cursory knowledge of URAC and HFAP credentialing requirements. Monitors regulatory sources to stay informed of rapidly changing rules and regulations that relate to credentialing processes. Reviews and processes all provider applications to Primary Partners (PO) and Covenant HealthCare Partners (PHO). Analyzes and resolves provider file issues, tracks progress on network management, and produces weekly reports. Reviews and analyzes provider file changes. Responds to provider inquiries received by letter, phone, or internal departments. Administers Re-credentialing of network providers. Reviews and monitors provider complaint and grievance files. Attends Credentialing Committee meeting and records meeting minutes to comply with NCQA requirements.

Ability to apply common sense understanding to carry out moderately complex, multi-step instructions and make appropriate independent decisions as necessary. Maintains close contact with Billing Department to provide updates on new hires, terminations, approvals from MCOs, and any other information billing department could need from credentialing. Maintains and updates the providers MD Staff credentialing profiles as outlined in the PHO Standard Operating Procedures and/or policy. Interact with various cross functional groups, complete the required auditing and reporting related to credentialing delegation, and ensure adherence with NCQA requirements for credentialing and recredentialing. Collaborate with the various departments to conduct the timely credentialing delegation audits Develop the post-audit reports based on audit findings and communicate those to the delegated entities, and credentialing leader. Ensure compliance with delegation monitoring and oversight requirements for credentialing functions. Adhere to policies and procedures related to delegation maintenance. Identify process improvement opportunities that organizationally decrease cost, improve quality, and increase efficiency. Maintain strict confidentiality of practitioner, company, and personnel information. Collaborate with Credentialing, Billing, and IT teams for seamless practitioner onboarding. Manage group and practitioner's attestations and required documents in credentialing database. Communicate