Medical Staff Services Specialist
Primarily responsible for provider credentialing supporting continuous quality improvement and certifications, to include new applicant credentialing, re-credentialing and ongoing maintenance of provider credentials, the coordination and administration of quality audits, clinical reviews and maintaining/updating credentialing and quality reports.
Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism and competence.
OUR CORE VALUES
ESSENTIAL SKILLS AND EXPERIENCE
- High School diploma or GED from an accredited institution, four (4) year college degree preferred
- 2+ years hospital credentialing and provider experience required
- Professional and effective oral and written communication skills
- Organizational skills; ability to multi-task and manage priorities; meet critical deadlines
- Proficient in Microsoft Excel, Outlook and Word and proprietary database applications
- Attention to detail, objectivity and accurate documentation skills
- Excellent customer service orientation with the ability to communicate professionally both verbally and in writing with providers, payers, staff and leadership.
NONESSENTIAL SKILLS AND EXPERIENCE
- Three (3) years of experience in community health
- Knowledge of medical terminology
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job related selection or promotional criteria.
- Create and facilitate completion of clinician applications for payers and facilities to ensure timely credentialing and enrollment.
- Process credentialing and re-credentialing applications of providers
- Communicate with providers via phone, email or letter to verify and correct any paperwork rejected from insurance companies.
- Identify, obtain, verify and maintain database with up to date providers’ credentialing information
- Acts as primary contact for internal and external customers for administrative matters associated with Medicare/Medicaid participation process, other insurance participation process and troubleshoots and resolves issues as they arise
- Maintain frequent communication with insurance plans to track progress of credentialing approvals for providers
- Updating credentialing documents as needed/required
- Update contracted facilities and payers with current credentials on clinicians
- Administer and coordinate audits and reviews to support certification and continuous quality improvement
- Escalate credentialing issues to management and make recommendations for continuous improvement regarding credentialing process
- Maintain strict confidentiality of information and files in compliance with internal policies and HIPAA
Additional Duties and Responsibilities
- Performs other duties as requested or assigned
All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team based model to promote wellness and improve health outcomes.
Adherence to Compliance and Code of Conduct
All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance, and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
Work environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic area.
In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630, if the essential functions of this position cannot be performed in a satisfactory manner by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization.