Credentialing Coodinator - Provider Enrollment
Wellstar Health Systems

Facility: 1800 Parkway Center

Job Summary:

The Credentialing Coordinator will gather and analyze primary source verification of the credentialing and re-credentialing of applicants in accordance with the standards of all applicable accrediting and regulatory agencies (JCAHO, HCFA, NCQA, other) as well as the WellStar Health System Medical Staff Bylaws and Rules and Regulations and WellStar Health System policies and procedures. Incumbent will perform the initial and re-credentialing of WellStar Medical Group & WellStar Clinical Partners employed providers with all managed care plans and third-party payors by enrolling them through individual or delegated processes in accordance with standards of the WellStar Health System policies and procedures, Medical Staff Bylaws and WellStar Managed Care contracts.

Core Responsibilities and Essential Functions:

Delegated Credentialing
- Works with Medical Staff Service and collects all required primary source verification to complete credentialing
- Conducts and prepares facility credentialing and re-credentialing applications with payors
- Answer inquiries regarding provider credentialing status
- Research and problem solve internal and external inquiries on a regular basis
- Work with external and internal customers to ensure timeliness and accuracy of all files
- Request Site Reviews when required for Primary Care, OB/GYN, and High Volume Specialists as applicable
- Prepares files for CMO review and for Credentialing Committee review
- Prepares reports for the Credentialing Committee and the Board of Directors
- Notify departments of approved providers
- Works closely with staff in preparation and presentation for Credentialing Committee Meetings
- Interface with various company departments to assure coordination of policies
- Other duties as assigned Compliance
- Oversees delegated credentialing compliance per NCQA.
- Conducts pre-assessment delegated site surveys and annual delegated visits
- Maintains required logs and prepare reports, as needed
- Maintains proficient knowledge of NCQA and AHCCCS standards, and recommends policy revisions to the Director
- Perform ongoing internal audits on credentialing and re-credentialing files for ongoing monitoring of accuracy
- Revises the Credentialing Plan and/or policies at least annually, or as needed
- Maintain all physician and provider files for compliance
- Remains educated and updated on all rules, regulations and standards related to the role. Organization
- Keeps all files and documents in an organized and efficient manner.
- Maintains the confidentiality of all information by following appropriate corporate policies and securing all documents/information appropriately.
- Utilizes the appropriate databases to improve efficiency and reducing the need for a live file.
- Challenges the processes on a continual basis to improve outcomes and productivity
- Create standardized forms and letters for credentialing and re-credentialing ensuring accuracy and consistency of communication Team
- Collaborates with Managed Care, Medical Billing and other related departments to look for efficiencies and performance improvement.
- Fosters positive working relationships between fellow team members in enrollment and other departments.

Required Minimum Education:

High school diploma equivalent Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Cert Provider Credential Spec-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of credentialing experience in a hospital or managed care setting and/or medical staff services or three (3) years minimum in progressively responsible position in a complex business/administrative office setting, which includes working with faculty, medical staff or other professional groups Required

Required Minimum Skills:

Working knowledge of State and Federal regulatory and Joint Commission and NCQA requirements regarding credentialing

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