Credentialing Specialist

New Haven, CT
Oct 4, 2018

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Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
EEO/AA/Disability/Veteran
Summary:
Under the supervision of the Manager, the Credentialing Specialist is responsible for the execution of all activities related to the appointment or re-appointment of Members and Affiliated Members of the Medical Staff. This includes thorough evaluation of the application upon receipt against the Medical Staff Bylaws to determine eligibility and troubleshooting all steps throughout the processing of each application to ensure completeness and compliance with Medical Staff Bylaws, Department Policies and Procedures, Joint Commission (JC), State of Connecticut Department of Public Health (DPH), Centers for Medicare and Medicaid Services (CMS) and National Committee on Quality Assurance (NCQA) regulations. The Credentialing Specialist is also responsible for the completeness and accuracy of all data entry including demographic and clinical privilege information which is used both in the Department of Physician Services and hospital-wide.
Responsibilities:
  • 1. New Medical Staff Applications
  • 1.1 Receives and reviews all new applications and communicates with applicant regarding outstanding required documentation within five (5) working days of receipt.
  • 1.2 Keeps complete documentation for all communication with applicant and others contacted in regarding the application from receipt of the application to approval.
  • 1.3 Responsible for ensuring accurate data entry of all demographic and other credentialing information consistent with Department Policies & Procedures. Responsible for maintaining and updating this information to keep current relative to the stage of application processing.
  • 1.4 Responsible for accuracy of all required background checks and verifications, including, but not limited to: National Practitioner Databank, Federation of State Medical Boards, medical licenses, DEA, CT state narcotics certificate, OIG, EPLS, FBI, google check, malpractice insurance coverage, medical school, internship, residency, fellowships, board certification and all others as indicated based upon the applicant''s history.
  • 1.5 Responsible for evaluating the background, experience and practice history of each applicant and soliciting appropriate references to support the individual''s specific request for clinical privileges.
  • 1.6 Responsible for communicating with the applicant regarding appropriate documentation to support requests for clinical privileges as required by current policies and credentialing guidelines. Advises applicants as to the proper format and content of information to be sent.
  • 1.7 Conducts initial and on-going follow up with applicant to facilitate completion of the file consistent with deadlines.
  • 1.8 Responsible for conducting regular meetings with representatives from groups that consistently have multiple applications in process to provide formal update and documentation of outstanding issues.
  • 1.9 Continuously reviews each file in process to evaluate whether additional information is needed to support requested privileges and, following review, communicates with applicant, reference writes or others to solicit necessary information.
  • 1.10 Conducts comprehensive review of file for completeness in preparation for approval by Manager or Director, Physician Services.
  • 1.11 Communicates with Clinical Department Leaders once application is complete. Points out any issues that need to be addressed to ensure compliance with Medical Staff Bylaws and regulatory requirements. Facilitates Chief''s review and recommendation process flagging any issues identified during the credentialing process. Responsible for ensuring that signature process occurs within timeframes specified by the Medical Staff Bylaws and alerts Manager appropriately.
  • 1.12 Facilitates timely review by the Credentials Committee Sub-Committee or Credentials Committee.
  • 1.13 Prepares files for Manager when Credentials Committee review is indicated.
  • 1.14 Follows up and through on any matters as requested by the Chiefs, Credentials Committee or Credentials Sub-Committee.
  • 1.15 Communicates with Admitting, Medical Records, Security, Operating Room and other Hospital departments to ensure that they are aware of new Medical Staff approved by the Credentials Committee in a timely manner so that new Medical Staff can begin to function in the organization.
  • 1.16 Posts newly approved privileges and prepares and sends personalized appointment letters to each applicant including, as appropriate in each case, reference to relevant hospital policies and procedures.
  • 1.17 Follows up on any outstanding or imminently outdating information until resolved to ensure that the Medical Staff database properly represents current information.
  • 2. Medical Staff Re-Appointments
  • 2.1 Responsible for ensuring that re-appointment applications are appropriately prepared and distributed to eligible Medical Staff six (6) months prior to re-appointment due date.
  • 2.2 Evaluates list of individuals to be re-appointed to determine appropriate documents to send to each including, but not limited to: privilege delineation, conscious sedation material, etc.
  • 2.3 Reviews content of applications to verify that all required material has been received. Notifies applicant of any missing documentation within five (5) days of receipt of application.
  • 2.4 Keeps complete documentation for all communication with applicant and others contacted in regarding the application from receipt of the application to approval.
  • 2.5 In accordance with Department Policies & Procedures, contacts individuals who have not submitted applications by due date. Prepares and distributes first and second notice letters as appropriate for individuals who have not submitted applications by due date in accordance with Department Policies and Procedures.
  • 2.6 Updates Medical Staff database with changed information.
  • 2.7 Performs all required background checks and verifications, including, but not limited to: National Practitioner Databank, Federation of State Medical Boards, medical licenses, OIG, EPLS, Google check, hospital verifications, malpractice insurance coverage, board certification and all others as indicated based upon the applicant''s history.
  • 2.8 Consistent with Department Policies & Procedures and Medical Staff Bylaws, continuously reviews each file in process to evaluate whether additional information is needed to support requested privileges and, following review, communicates with applicant, or others to solicit necessary information or documentation of clinical activity.
  • 2.9 Responsible for soliciting and obtaining appropriate references as applicable to support request for privileges.
  • 2.10 Coordinates with Department Data Manager and other Hospital staff accordingly to obtain appropriate data to support appropriate re-appointment evaluation.
  • 2.11 Responsible for compiling all required documentation on each applicant, reviewing for completeness and providing to Manager for review. Responsible for completing process within timeframes required to ensure compliance with JC standards regarding the limitations on the duration of appointments. Follows up in a timely manner on any matters as requested by Manager.
  • 2.12 Prepares completed reappointments for circulation to the appropriate Chiefs for their action. Facilitates distribution among Chiefs remaining cognizant at all times of the time limitations allowed by the Bylaws for Chiefs'' review as well as JC standards.
  • 2.13 Upon return, reviews to ensure that Chiefs have completed all appropriate documentation.
  • 2.14 Provides completed re-appointments to Manager for presentation to Credentials Committee.
  • 3. Expirables Management / OPPE Support
  • 3.1 Responsible for conducting monthly verification of outdating CT State Licenses, DEA certificates and other certifications, maintaining appropriate documentation in Medical Staff database ensuring that all licenses/certifications are current. Notifies individuals in a timely manner of outdating documents. Notifies Manager in a timely manner about individuals who have not renewed in accordance with requirements. Ensures appropriate electronic documentation.
  • 3.2 Responsible for coordinating the annual update of CT Controlled Substance Certificates. Ensures that all current Medical Staff have appropriately renewed their certificates. Communicates accordingly with Medical Staff by e-mail or letter. Tracks this process and notifies Manager of issues and any who fail to renew. Ensures appropriate electronic documentation.
  • 3.3 Responsible for conducting annual review of NCCPA certifications to ensure that all Physician Assistants who are presently Affiliated Members of the Medical Staff have a current certification. Documents accordingly and notifies Manager of any who are not in compliance with requirements.
  • 3.4 Responsible for conducting monthly verification of outdating APRN and CNM certifications to ensure that all APRNs and CNMs who are presently Affiliated Members of the Medical Staff have a current certification. Notifies individuals in a timely manner of outdating documents. Documents accordingly and notifies Manager of any who are not in compliance with requirements. Ensures appropriate electronic documentation including update of relevant expiration date fields and scanning of images.
  • 3.5 Responsible for conducting monthly verification of board certification expirations for physicians, dentists and podiatrists. Monitors for compliance with requirements of Medical Staff Bylaws. Notifies individuals in a timely manner of outdating documents. Documents accordingly and notifies Manager of any who are not in compliance with requirements. Ensures appropriate electronic documentation including update of relevant expiration date fields and scanning of images.
  • 3.6 Responsible for collection of "peer" and "self" evaluations from APRNs and PAs consistent with Departmental Policy. Ensures documents are collected at a minimum of every nine (9) months from all relevant practitioners. Runs report to identify relevant practitioners and tracks return. Communicates in accordance with standard Department email and / or letters. Notifies manager of delinquent returns.
  • 3.7 Responsible for supporting the collection of OPPE evaluations for APRNs and PAs consistent with Departmental Policy.
    EDUCATION:
    Bachelor of Arts or Bachelor of Science Degree with a concentration in liberal arts or science strongly preferred. Experience in a hospital, medical group practice, or other similar health care environment and familiarity with physician specialties required. Previous experience in credentialing preferred.

    EXPERIENCE:
    Two to three years experience in the healthcare industry supporting an understanding of physicians and physician specialties required. CPMSM or CPCS desirable but not required.

    SPECIAL_SKILLS:
    Ability to work with a high level of accuracy involving extreme levels of detail. Must have a high level of customer service skills and professionalism. Must be able to perform responsibilities with minimal direct supervision. Must have exemplary organizational, communication and customer service skills. Must have strong writing skills and be able to compose written/electronic appropriate communication independently. Must have a general understanding of medical terminology. Must be able to work under pressure and towards strict deadlines while concurrently keeping track of multiple processes in multiple stages of completion. Strong computer skills particularly in Microsoft word. Experience with credentialing software system desirable. Must be able to use appropriate discretion and maintain strict confidentiality with respect to all physician information as applicable.

    ACCOUNTABILITY:
    Accountable for ensuring that all activities are performed consistent with JC, DPH, CMS and NCQA requirements as well as Yale New Haven Medical Staff Bylaws and Departmental Policies and Procedures. Responsible for using skills and completing credentialing process within desired timeframes and communicating appropriately with all involved parties. Responsible for ensuring the integrity of Medical Staff data.

    COMPLEXITY:
    Position involves very significant problem solving skills and interaction with physicians at all levels. There is significant pressure on the Credentialing Specialist to complete the application process within timeframes necessary to support clinical services but the Credentialing Specialist must concurrently ensure compliance with very strict regulatory requirements. The complexities of credentialing and privileging new medical staff have increased significantly and require an individual who has exemplary organizational skills, can remain calm and professional under pressure and able to communicate specifically and effectively to all interested parties. Data entry must be exact as information in the Medical Staff database directly feeds downstream systems at YNHH such that inaccurate data will have a significant negative impact. The individual must be able to understand, communicate and consistently apply numerous requirements relative to each applicant and ensure that the final work product is comprehensive, complete and accurate by all standards.

    PHYSICAL_DEMAND:
    Works in a office setting. Must be able to sit at a desk for extended periods of time and work at a computer. Must be able to walk as position routinely requires the delivery and pick up of documents throughout the Medical Center. Must be able to file. *CB
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    Job Info

    Job: 1815

    Department: Medical Staff Administration
    Category: Non - Clinical Other
    Status: Full Time
    Shift: DAYS
    Hours: 40.00