• Responds to phone requests from providers and staff on a variety of concerns, problems and issues; conducts necessary research and responds verbally or by correspondence as appropriate.
• Captures required credentials and enters them into the credentialing database. Maintain Universal Provider Datasource for all Medical & Psychology Staff
• Conduct activities related to initial credentialing, recredentialing, delegation, facility credentialing and ongoing provider file maintenance. Conduct in processes to remain compliant with all applicable regulatory/accreditation agencies (CMS, etc.).
• Assures data security and confidentiality. Adheres to HIPAA privacy regulations. This entails appropriate labeling of information and storage, and appropriately securing emails.
• Provides guidance to clinicians in completing credentialing requirements. Maintains knowledge of current issues, trends, and changes in the laws and regulations governing clinician credentialing
• Ensures the credentialing and recredentialing of providers is coordinated in an accurate and up-to-date manner and that this information is disseminated internally and externally and in a timely manner.
• Collaborates with department management the streamlining and updating of credentialing processes. Closely monitors information collection and is cognizant of all information received; evaluates adequacy and quality and pursues additional information if necessary for effective and comprehensive peer review decision-making. Immediately reports to department management any providers credentialing information identified as adverse to the provider or enrollees.
• Monitors system reporting for accuracy. Assists in the maintenance of system identification for staggered credential renewals.
• Maintain Physician Directory in necessary data bases. Collaborate with Patient Access Services to ensure physician demographic information is accurate and up to date.
• Provide facility updates to payers regarding lock box, contacts, site location changes.
• Create and maintain provider grids.
• Liason for designated RWJBH entity(ies) pertaining to hospital/ancillary/professional initiative to manage various contracts (Managed Care Payer Services focused) Provide an Administrative role with contract tracking system. Enter new users with their perspective security sign on.
• Liaison between CSH physician practices and billing company for support and maintenance of professional billing system.
• Builds and Maintains electronic credentialing system for CRPN and individual credentialing for assigned entity(ies).
• Supports the Director and other Managed Care Department staff on special projects as assigned.
• Assists Patient Accounting with customer service issues regarding nonpayment from providers due to non compliance.
• Credentials facility and staff with Government Payers.
• Handles Medicare/Medicaid certification for new off-sites.
• Oversee and coordinates the implementation and issuance of the National Provider Identifier (NPI) for all physicians, psychologists, psychotherapists as well as the organization. Assists therapists in obtaining their registrations.
• Handles communication calendar for training, education and other necessary sessions/meetings for the department with management. Including overseeing the coordination of the implementation and on-going creation and distribution of a Credentialing Newsletter electronically to all areas in which professional or facility credentialing.

Job Requirements:

• Bachelor Degree or equivalent experience
• 5-7 years experience in Healthcare or equivalent experience
• Excellent written and verbal communication skills
• Experience with CAQH and other payer credentialing systems preferred.
• Knowledge as well as practical experience in either NQCA or TJC credentialing standards preferred.