What are the responsibilities and job description for the HP Credentialing - CME Spec position at Driscoll Health?
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General Purpose of Job:
The Credentialing Specialist is responsible for managing and completing the credentialing of Driscoll Health Plan (DHP) managed care network providers (practitioners and institutions), and assist with the oversight of delegation of credentialing to provider groups. This position ensures completeness of all required documentation for credentialing/recredentialing, facilitates the credentialing process, and maintains provider data integrity per DHP policy, federal, state and accreditation requirements. Responsible for providing support to DHP Network providers to ensure efficacy of the credentialing process.
Essential Duties and Responsibilities:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or Health Plan administration as required.
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Maintains utmost level of confidentiality at all times.
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Adheres to DHS/DHP policies and procedures.
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Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
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Facilitates receipt of necessary documents and credentialing applications.
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Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outline in DHP policies/procedures regulatory requirements and accreditation standards URAC/NCQA.
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Supports the Primary Source Verification (PSV) functions with the Credentialing Verification Organization (CVO), to include entry of CVO data in the DHP credentialing management system, quality review of documents to ensure all required guidelines are met.
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May conduct primary source verification for initial/re-credentialing applications in accordance with defined workflows and established policies and procedures if CVO documentation is outside timeline requirements.
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Imports all applications from the online application portal in accordance with policy for data standardization as needed.
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Communicates with health care providers to clarify questions and request any missing information.
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Responsible for the follow-up on missing data and/or discrepancies in accordance with established time frames and based on knowledge of general credential processes.
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Maintains integrity of the credentialing database and all practitioner records. Utilizes appropriate database tracking reports to ensure accuracy and thoroughness of imported data as well as data that may be entered manually.
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Serves as a liaison with provider groups, office managers and providers regarding managed care credentialing applications, statuses, and missing information.
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Submits required reports, ad hoc reports, and completed projects to management in a timely manner.
Education and/or Experience:
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High school diploma or general education degree (GED) required.
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Associate's degree or equivalent from a technical school or some college education preferred.
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2 years health care administration, managed care or customer service experience required.
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Credentialing experience highly preferred.
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Experience with MS Office Word and Excel required.
Certificates, Licenses, Registrations:
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CPCS Certification preferred.
HUMAN RES SPEC I - Human Resources
Texas Department Of Criminal Justice -
Beeville, TX
