Credentialing Verification Specialist

Remote work from Illinois, Wisconsin, Indiana, and Iowa

Description

The Credentialing Verification Specialist reflects the mission, vision, and values of NM, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Credentials Specialist is responsible for examining credentials and processing applications through to completeness for physicians and other health care practitioners applying to NM for appointment, clinical privileges, and/or reappraisal/ renewal in compliance with all standards. This position provides first contact to professional applicants and NU/NMG credentialing staff.

Responsibilities:

• Initiate, verify, examine, and maintain the confidential credentials process for all professional applicants to NM (physicians, dentists, psychologists, advanced practice nurses, physician assistants, designated clinical fellows and ancillary providers as added from time to time to meet organizational needs and imperatives).
• Ensure compliance with all regulatory and NM established criteria that the applicant is able to practice in the state of Illinois (or other states as directed by NM) and at NM affiliates and that current, verified documentation is on file (licenses[s], malpractice liability insurance, board certification, etc.).
• Examine application for completeness and all required documentation. Examine information reported for missing data elements, timelines and time gaps. Identify as acceptable or adverse. Conduct follow-up with applicant on identified adverse elements. Investigate as necessary through to final resolution.
• Perform primary source verification of all required credentials data elements and direct inquiries to all required data banks, profiling providers, licensing/regulatory agencies, etc. in compliance with all accreditation (JC, CMS, IDPH, NCQA), federal, state and NM requirements.
• Examine and evaluate credentials information and results obtained by cross-referencing and comparing to information reported on application and curriculum vitae. Identify as acceptable or adverse. Examine for compliance with NM medical staff qualifications and criteria. Investigate discrepancies and misstatements with applicant and other primary sources as necessary through to final resolution. Identify key issues in core credentials data. Report identified adverse information and unresolved questions to CVO leads and/or Director as appropriate.
• Determine when investigation and credentials process is complete by comparing and contrasting file to requirements and verifying that all documentation meets standards. Identify and flag time-sensitive items for reverification. Generate profile and reports.
• Maintain accurate and current credentials database for all applicants. Record all credentials information immediately upon receipt. Monitor and track application status and credentials process. At all times, any department staff member must be able to access an applicant's electronic record and determine current status.
• Maintain tracking documentation as per local standards to ensure continuity.
• Provide first contact and customer service to professional applicants and credentialing staff. Communicate regularly to appraise of application status and/or any missing items.
• Perform all essential functions (#s 2-6 having potential for high-risk exposure for the hospital) in compliance with all accreditation standards (JCAHO, NCQA), federal and state laws and regulations (IDFPR, IDPH, NPDB, etc.) and NM/medical staff bylaws and policies/procedures. Maintain knowledge base as applicable to credentialing.

Qualifications

Required:

• Associate's degree plus 2 years of consecutive work experience in medical staff services or credentials verification; healthcare administration; or payor/managed care enrollment OR in lieu of degree must have 4 years of consecutive work experience in medical staff services or credentials verification; healthcare administration; or payor/managed care.
• Strong knowledge of Microsoft Office products
• Excellent interpersonal, customer service, and communication skills (oral and written)

Preferred:

• Bachelor's degree and 3-5 years credentialing experience

Equal Opportunity

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.