Credentialing Coordinator

The Credentialing Coordinator coordinates the processes for medical staff/advanced practice professional credentialing, privileging, delegated payer, and allied health professional credentialing to ensure that legal and regulatory requirements are met at all St. Charles Health System’s facilities. Exercises judgment and discretion in recognizing legal implications and patient safety issues through the credentialing and privileging functions. Collects and prepares detailed information to report potential quality of care issues and behavioral problems to ensure safety and quality for all patients who receive care within St. Charles Health System. This position does not directly manage any other caregivers.

Essential Functions And Duties

Complies with internal and external policies, guidelines and standards.

Verifies and collects documents that support providers have met and maintain the eligibility threshold for their privileges. Finds, investigates and reports any possible flags, patterns of negligent patient care, and negative behavior and notes all findings.

Processes initial and reappointment applications and privileging requests as defined by internal and external policies, procedures and guidelines. Must be knowledgeable of the Medical Staff Bylaws and Rules and Regulations, The Joint Commission, CMS, and NCQA guidelines, URAC and Oregon State Law. Ensures processes are coordinated timely and accurately in compliance with schedules.

Organizes and maintains provider files including obtaining current/updated copies of essential documents, loading/scanning all documents which contain confidential and peer protected data and documents. Updates individual files in company credentialing software and databases while adhering to the established data entry conventions.

Interfaces and maintains professional relationships with applicants, Medical Staff leadership, state professionals and licensing bodies, and other partnering St. Charles leadership and departments as needed.

Creates accurate credentialing reports with proper information so the Medical Staff Credentialing Committees can review and make appropriate recommendations to St. Charles Health System governing bodies for medical staff membership and privileging approvals, denials, suspensions or revocations.

Creates accurate delegated payer credentialing reports for the Medical Director (or designee) and the Delegated Payer Credentialing committee.

Maintains provider records for auditing, and maintains close communication with all appropriate practitioners to ensure that files are returned on time, records are up-to-date, consistent and complete. Tracks status of responses, identifies any discrepancies in information and conducts follow up if applicable. Collaborates with provider to obtain any missing items and will provide a status update on the application and/or privileges.

Maintains working knowledge of Medical Staff governance and flow of information throughout the Medical Staff Structure and the Health System’s leadership to ensure patient safety.

Maintains and protects the confidential records of the credentialing and privileging processes which may be required in subsequent internal investigations and/or external legal disputes. Handles and protects sensitive peer protected and confidential information with the highest level of integrity.

Exercises a high degree of independent judgment and initiative in response to complex, sensitive issues, decision making, and descretion. Requires limited direction and guidance. Addresses moderately difficult problems.

Conducts all activities with the highest standards of professionalism and confidentiality. All written, email, and verbal communications must be conducted in a professional, courteous, collaborative and timely manner.

Serves as an organizational resource for data information related to the Health System’s organized medical staff providers.

Supports the vision, mission and values of the organization in all respects.

Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service in a manner that promotes goodwill, is timely, efficient and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION

Required: High School diploma or GED

Preferred: Bachelor’s degree

LICENSURE/CERTIFICATION/REGISTRATION

Required: N/A

Preferred: Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS)

Experience

Required: Minimum of 3 years’ experience in a healthcare setting.

Preferred: Credentialing coordinator/payer credentialing experience