Duke University Health System (DUHS) Job Descriptions
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CREDENTIALING SPECIALIST
Job Title: CREDENTIALING SPECIALIST
Job Code: 4614
FLSA: N
Job Level: D1
Revised Date: 12/06/2021
Supervisory Responsibility: NO
General Description of the Job Class
Under the supervision of the Manager of DUHS CVO and the Lead Credentialing Specialist, the Credentialing Specialist is responsible for all aspects of the credentialing for all medical providers who provide patient care at Duke University Health System (DUHS), Responsible for ensuring providers are credentialed in accordance with The Joint Commission, NCQA, CMS, and AAAHC Standards for health plans, hospitals, ambulatory care centers and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of appointments, and all-time limited credentials.
Duties and Responsibilities of this Level
Processes initial and/or reappointment applications for DUHS, and any future Health System acquisitions according to the Medical Staff Bylaws, related policies ensuring compliance with regulatory requirements.
Obtains verification from primary sources for all regulatory requirements and monitors all applications assigned for credentialing to provide updates to applicants and documents in the credentialing system in compliance with regulatory standards.
Researches and maintains current and accurate data for all providers for the Health System within the Credentialing database.
Verifies the legitimacy of practitioner information with the primary source of the credentials and in accordance with the accreditation regulatory standards, and state/federal laws for universities, licensing agencies, hospitals and certification bodies.
Maintains a complex credentialing database with up-to-date practitioner information, including medical license, drug enforcement administration (DEA) certificate professional liability insurance, board certifications and renewal period expiration dates.
Executes queries for the National Practitioner Data Bank (NPDB) for initial appointment and reappointments through NPDB Continuous Query in the Credentialing database.
Ensures that any reports received through the queries are flagged for the Medical Staff Offices
Presents complete Health System applications with credentialing verification materials and flags any concerns for initial and reappointment applications for the Medical Staff Offices to act upon.
Ensures data integrity within the Credentialing database for physician practice demographic information and ensuring it is compliant with health plans, agencies and other entities.
Analyzes complex information in the credentialing application process, ensuring there are no time gaps, we are obtaining the documentation required for compliance with policies, regulatory standards, and State and Federal laws.
Maintains confidentiality of all provider information within our credentialing database, as well as documentation gathered through the credentialing process.
Provides credentialing, re-credentialing and privileging verifications in accordance with regulatory standards, and state/federal laws.
Composes, proofreads or edits formal correspondence, memoranda, and short reports for internal and external circulations. Assembles attachments and corresponding materials. Reviews outgoing materials for completeness, dates and signatures.
Serves as a credentialing subject matter expert with internal and external contacts on administration of program and/or program policies and procedures.
Applies office standards, policies, procedures and authority levels when responding to questions from both internal and external customers.
Organizes and maintains resource information and job procedures pertinent to responsibilities.
Prepares a variety of documents, records, reports, etc. as needed to perform job responsibilities.
Performs other duties as assigned.
Lead Credentialing Specialist Duties and Responsibilities:
In addition to above duties as Credentialing Specialist the Lead Credentialing Specialist would be responsible for the following duties:
Monitors, measures and maintains timeliness of all initial and re- credentialing activities.
Audits initial and reappointment applications for completeness, accuracy and timeliness once the CVO verification process has been completed by the Credentialing Specialists and the application packets are turned over for review.
During the audit, if the file is deemed complete, the Lead Credentialing Specialist routes the file to the appropriate Medical Staff Office in the Health System for their process to begin. If deemed incomplete, the file is returned to the Credentialing Specialist to retrieve the missing information required for policy and regulatory compliance.
Distributes, receives, assigns and tracks initial and reappointment applications, schedules, and other pertinent confidential information regarding credentialing/re-credentialing of providers for the Duke Health System facilities, with correctness and completeness.
Communicates with providers, office staff, department contacts, and Duke entity Medical Staff Services Coordinators, etc., regarding initial and re-credentialing application status and other activities throughout the process.
Educates and trains the Credentialing Specialists with interpretation, explanation and following all regulatory guidelines, including medical staff bylaws, rules and regulations and policies.
Required Qualifications at this Level
Education
Work requires analytical, communications and organizational skills generally acquired through completion of a bachelor's degree program.
In lieu of bachelor's degree, four years relevant experience in Managed Care or Medical Staff Credentialing/Privileging (in addition to the experience requirement for the role)
Experience
One year of experience in a Medical Staff/Managed Care credentialing office.
Lead Credentialing Specialist Experience: Three years of experience in a Medical Staff/Managed Care credentialing office.
Degrees, Licensure, and/or Certification
Certification by NAMSS (CPCS and/or CPMSM) preferred
Knowledge, Skills, and Abilities
Maintains knowledge, as the Subject Matter Expert for compliance of delegated credentialing contracts of current health plan and agency requirements in the managed care contracts for credentialed providers.
Maintains knowledge, as the Subject Matter Expert of state/federal laws, regulatory standards for accreditation purposes, and DUHS Bylaws, policies and procedures.
Distinguishing Characteristics of this Level
N/A
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.