PeaceHealth is seeking a Provider Data Specialist (aka Credentialing Specialist) for a Full Time, 1.00 FTE, REMOTE Day position.
Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
Responsible for coordinating, processing, monitoring and maintaining the initial and reappointment confidential credentialing processes for medical staff and allied health practitioners, ensuring timeliness and compliance with PeaceHealth standards and criteria as well as all legal, regulatory and accreditation requirements. Perform primary source verification according to established policies. Responsible for the accuracy and integrity of the credentialing database system. Coordinates Payer Enrollment service processes for governmental and non-delegated third-party payers for Providers associated with PeaceHealth.
- Initiates, coordinates, processes and monitors initial appointment and reappointment credentialing applications. Maintains tracking mechanisms.
- Gathers, verifies and evaluates healthcare provider credentials for initial and recredentialing applications; identifies potential issues; determines if further investigation or information is necessary and makes appropriate inquiries; assesses completed applications to ensure PeaceHealth criteria are met and all necessary elements are present and correct.
- Ensures timely enrollment of new providers with 3rd party and government payers; and maintenance of existing active physicians and advanced practice providers. Enters and maintains data in the credentialing database. Assists with maintaining the expirables tracking system.
- Maintains credentials files and related records. Processes application requests from contracted entities; ensures correct application forms and complete packets are sent to provider.
- Communicates with PeaceHealth Medical Staff Offices and practitioners regarding credentials files and processes. Provides verification of PeaceHealth membership and clinical privileges for current and former credentialed providers as requested by internal or external organizations; maintains database and other records.
- Enters and maintains data in the credentialing database, credentials files and related records as needed.
- Prepares and tracks revalidation and recredentialing applications. Prepares and submits applications for new providers and submits them to PeaceHealth contracted payers and government health plans.
- Performs other duties as assigned by department leadership.
- High School Diploma or equivalent.
- Two years business college, preferably in medical staff or health information technology, required or equivalent combination of education and experience that provides the requisite knowledge, skills and abilities to perform the job.
- Minimum of 2 years credential verification or healthcare administration required.
- Certification by the National Association of Medical Staff Services (NAMSS) as a Certified Professional Medical Staff Management (CPMSM) or a Certified Professional Credentialing Specialist (CPCS) required (or obtain certification within three years of employment).
- Excellent critical thinking and problem-solving skills
- Detail oriented with demonstrated accuracy, organizational and time management skills
- Working knowledge of credentialing database software; Cactus software preferred
- Knowledge of legal, regulatory and accreditation credentialing requirements preferred
- Proficiency in MS Office applications, i.e., Word, Excel, etc.
- Excellent verbal and written communication skills
- Excellent customer service skills
- Ability to support multiple priorities, projects and display flexibility in a fast paced and challenging work environment
- Knowledge of medical terminology preferred
REGION/LOCATION SPECIFIC NOTES
May include the following responsibilities for the delegated credentialing program:
Participates in and maintains the delegated credentialing program to ensure all regulatory and accreditation requirements are met and data transmittal is performed according to contract terms; responds to delegated payer inquiries; coordinates, prepares and represents CCO for all delegated and organizational credentialing surveys and audits; maintains effective working relationships with payer representative. Maintains organization credentialing program(s) and payer enrollment to ensure they are regulatory and accreditation compliant. Assists contracted entities and delegated payers with credentialing issues that affect billing or reimbursement; ensures delegated credentialing processes for new PeaceHealth clinics, services and providers are ready prior to start date.
- Work requires fairly light physical exertion from up to 65% of the time.
- Ability to lift objects weighing 30 lbs. or less.
- Work is performed under normal working conditions with adequate lighting and ventilation.
- Job duties frequently require intense concentration and attention to detail (up to 65% of work time).
See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.
For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.