Credentialing Coordinator

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Responsible for timely payer credentialing and/or recredentialing of providers for West Virginia United Health System. This includes, but is not limited to, processing new applications, recredentialing applications, monitoring expiring documents, and monthly monitoring of sanctions.

MINIMUM QUALIFICATIONS : EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School diploma or equivalent and one (1) year of administrative related experience OR Associates, Bachelors or Masters degree in lieu of experience

PREFERRED QUALIFICATIONS : EXPERIENCE:

1. Knowledge of NCQA and CMS regulations regarding provider credentialing.

CORE DUTIES AND RESPONSIBILITIES:  The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Coordinates provider credentialing by tracking applications, keying data into the credentialing program, monitoring information requested from providers, and assisting with preparation of credentials files for review in accordance with NCQA and CMS regulations.

2.    Performs primary source verification of provider information in compliance with NCQA and CMS standards.

3.    Maintains working knowledge of NCQA and CMS standards.

4.    Reviews and analyzes credentialing applications and prepares correspondence requesting additional or missing information.

5.    Regularly initiates and engages in a variety of discussions with contacts, both internal and external to HPN in order to obtain or relay information concerning network participation, contract activity, and credentialing activity.

6.    Participates in special projects as assigned by Supervisor. PHYSICAL REQUIREMENTS:  The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

7. Frequently experiences mental/visual fatigue from data entry, filing, etc., and from the administrative pressure of the office.

8. Must be capable of adapting to various workloads, work assignments and varying work environments.

9. Prolonged sitting

SKILLS AND ABILITIES:

1. Ability to function effectively in a demanding and fast paced environment.
2.    Proficient computer skills including but not limited to thorough knowledge of Windows and Microsoft Office including Excel, or similar applications.
3.    Possess excellent organizational and prioritization skills.
4.    Must be detailed oriented and possess excellent grammar skills.
5.    Possess professional communication skills.

Additional Job Description:

Scheduled Weekly Hours: 40 Shift:

Exempt/Non-Exempt: United States of America (Non-Exempt) Company: SYSTEM West Virginia University Health System Cost Center: 649 SYSTEM Managed Care and Payer Relations