Medical Staff Office Specialist II (KFH/HP)

Job Summary

Requests and reviews primary source information and verifications, with limited guidance. Identifies and begins to plan for resolution of standard gaps in vendor relationships and escalates, as needed. Serves as a main point of contact for external queries regarding practitioner status. Evaluates applications and supporting documents. Applies and reviews improvements to credentialing and privileging processes. Evaluates standard practitioner sanctions. Participates in surveys and audits of credentialing entities. Supports cost-effective due process. Identifies basic adverse actions/issues. Reviews Data to aid in auditing and reconciliation of data. Develops standard informational documents. Maintains working relationships with key stakeholders. Maintains awareness of policies and starts to provide standard consultations. Processes provider enrollment. Gathers and communicates relevant information to appropriate parties. Assists and maintains data systems, applications, and control. Plans and schedules own work to enact and analyze data. Building upon working knowledge of understanding of database structures and data.

Essential Responsibilities

• Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members.
• Listens to, addresses, and seeks performance feedback.
• Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them.
• Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work.
• Assesses and responds to the needs of others to support a business outcome.
• Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship.
• Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information.
• Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
• Participates in training and regulatory awareness by: may be assisting in the facilitation of orientation and training to newly appointed physician leaders for effective oversight and management of their departments credentialing, proctoring, privileging and reappointment processes, with general directions; developing standard informational/educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies; planning for own maintenance of working relationships with key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making; and maintaining awareness of current internal policies and relevant external regulations and starting to provide standard consultative expertise to internal parties.
• Assists in quality assurance, improvement, and resolution by: obtaining and learning to evaluate standard practitioner sanctions, complaints, and adverse data to ensure compliance, with general directions; participating in ongoing assessments of standard governing documents (e.g., bylaws/rules and regulations/policies and procedures) to ensure continuous compliance; participating in surveys and audits of credentialing entities (e.g., CMOs, delegates and health plans for NCQA); planning own efforts to support facilitation of efficient and cost-effective due process that complies with internal fair hearing and appeals policies and external legal and regulatory requirements; identifying and escalating and preparing standard adverse actions/issues (e.g., sanctions and complaints) to the credentialing committee taken against a practitioner/provider in accordance with applicable law and contractual requirements to the necessary parties; and reviewing, evaluating, and presenting data to team to aid in auditing and reconciliation of data between different departments, monitoring of credentialing and contracting.
• Processes provider enrollment by: gathering and performing detailed and thorough review of the standard information used to submit the enrollment applications; preparing and submitting data and applications to the contracted and government payors in a manner commensurate with their expectations, policies and accreditation standards, with general directions; regularly enacting standards for communicating enrollment status to all stakeholders in a clear and timely manner; and may be notarizing public documents.
• Conducts primary source verification and management by: requesting, obtaining, and reviewing information from primary source verifications to evaluate applications and provided sources for alignment, with limited guidance; identifying standard gaps and opportunities in vendor relationships, and escalating to manager as appropriate; identifying, investigating, and executing generally outlined plan for resolution of inaccurate primary source process, verifications, applications, and adverse information, escalating as appropriate; verifying and documenting expirable using acceptable verification sources to ensure compliance with accreditation and regulatory standards, with general directions; and serving as main point of contact for external queries regarding practitioners status, responding in a timely manner.
• Assists in governing databases by: building working knowledge of structures and data within a computerized data base of physician data for use in the credentialling and appointment process, in alignment with department guidelines.
• Applies and ensures control and application of data systems by: building upon knowledge of data structures, system functions, creations of workflows, portal management and coordinating the access and controls of data; enacting establish processes for auditing, assessing, procuring, implementing, effectively utilizing, and maintaining practitioner/provider and delegated credentialing processes and information systems (e.g., files, reports, minutes, databases) as outlined; and maintaining a consistent understanding of and (e.g., electronic board memos) to ensure compliance.
• Enacts and analyzes data by: planning and scheduling own work to ensure the efficient file completion, conduct privileging analyses, and verify privileging to the appropriate specialty/facility, based on data, with minimal day-to-day supervision; and leveraging standard tools and policies to support knowledge management, record-keeping, and internal and external communication.
• Enacts credentialing and privileging maintenance and management by: planning and scheduling own completion and evaluation of application and supporting documents for completeness and to determine applicants initial eligibility for membership/participation; providing standard support to team in interactions with practitioner during application process, providing timely updates and additional information as requested; preparing and completing standard documents related to practitioner-specific data for presentations to decision-making bodies (e.g., committees); and applying defined and reviewing suggested improvements to credentialing and privileging processes for all practitioners/providers to gain insight, with minimal day-to-day supervision.
  
  

Minimum Qualifications

• Associates degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum one (1) year(s) of experience in clinical credentialing, accreditation and regulation, licensing, health care, quality or a directly related field OR minimum two (2) years' experience in clinical credentialing, accreditation and regulation, licensing, or a directly related field.
  
  

Additional Requirements

• Knowledge, Skills, and Abilities (KSAs): Project Management; Credentialling IT Application Software