Medical Staff Credentialing and Provider Enrollment Coordinator

Summary

The Medical Staff Credentialing and Provider Enrollment Coordinator is responsible for executing all aspects of medical staff credentialing and provider enrollment to ensure compliance with organizational policies Medical Staff Bylaws and regulatory and accreditation standards. This role processes appointments reappointments privileging requests temporary privileges leave of absences staff category changes name changes resignations and all provider enrollment re-verification and terminations with federal managed care and other third-party payors.

The coordinator partners with physician and administrative leaders to develop draft and maintain clinical privileging criteria ensures timely and accurate enrollment activities and supports organizational readiness for reimbursement audits accreditation and regulatory reviews. Additionally the role maintains up-to-date knowledge of regulatory requirements applies best practices to credentialing and enrollment processes and assists with accreditation and regulatory survey preparation.

Education

Required: High School diploma or GED and a minimum of three years related experience.

Certification Registration & Licensure

None required.

Experience

Minimum of three years related experience and proficiency in Microsoft Office applications including Word and Excel; experience with credentialing systems CAQH and web portals for insurance enrollment; knowledge of billing; familiarity with accreditation organizations and their standards; and a high level of data-entry accuracy. Prior experience in Medical Staff Credentialing and Provider Enrollment is strongly preferred.

Responsibilities

• Manage and perform comprehensive credentialing and privileging processes for practitioners including initial applications reappointments temporary privileges leave of absence requests additional privilege requests staff category changes and resignations.

• Conduct critical analysis of all credentialing and privileging applications to verify eligibility flag areas of concern and resolve discrepancies in alignment with organizational standards.

• Maintain accurate and up-to-date internal and electronic files databases and tracking logs for credentialing privileging and provider enrollment ensuring integrity and proper documentation throughout the process.

• Provide administrative and meeting support for the Credentials Committee including preparation documentation and follow-up of actions and decisions.

• Process and maintain all aspects of provider enrollment and re-enrollment with federal state and commercial payors for practitioners and institutional groups including initial enrollment revalidations updates terminations including provider directory and CAQH review and updates. Ensure timely and accurate submission of enrollment applications re-enrollment forms and supporting documentation.

• Respond to and resolve issues related to provider network participation including eligibility denials of services and reimbursement discrepancies acting as a liaison between providers hospital staff and payor representatives.

• Develop and maintain positive relationships with internal and external stakeholders including practitioners leadership payors government and regulatory agencies and ensure the timely resolution of inquiries and complex issues.

• Ensure compliance with all applicable regulatory accreditation and payor standards including CMS NCQA and other federal and state requirements.

• Recommend and help implement process improvements and best practices to enhance operational efficiency and compliance.

• Assist with accreditation and regulatory survey readiness for credentialing functions.

• Provide backup support to colleagues and perform other duties as assigned.

Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race color religion sex sexual orientation gender gender identity national origin age marital status genetic information disability or protected veteran status.

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Applicants to and employees of this company are protected under federal law from discrimination on several bases. Follow the link above to find out more.

If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process you may contact Human Resources at .

Physical and Work Requirements
The physical demands and characteristics of the work environment described here are representative of those an employee will encounter in successfully performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The Dictionary of Occupational Titles Material Handling Classification is LIGHT. The employee must regularly lift carry or push/pull less than 10 pounds frequently lift carry or push/pull up to 10 pounds and occasionally lift carry or push/pull up to 20 pounds.

The employee is frequently required to hear and perform activities that require fine motor skills reach sit and speak. The employee is occasionally required to do repetitive motion and walk.

Specific vision abilities required by this job include color vision depth perception far vision near vision and peripheral vision.

The noise level in the work environment is usually quiet.