Credentialing Specialist Managed Care AdventHealth Corporate
Location Address: 1051 Winderley Place Suite 400 Maitland, FL 32751
Top Reasons To Work At AdventHealth Corporate
Immediate Health Insurance Coverage
Career growth and advancement potential
Full-Time, Monday â“ Friday
You Will Be Responsible For:
Coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
Conducts thorough background investigation, research and primary source verification of all components of the application file and ensures provider files are current and noted in detail in the system of record.
Achieves productivity standards as determined by management.
Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
Prepares credentials file for completion and presentation to the AHS Delegated Credentialing Committee (DCC) or other affiliated credentialing committees within AHS, including Clinically Integrated Network (CIN) committees ensuring file completion within time periods specified.
Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
Assists with managed care delegated credentialing audits; conducts internal file audits.
Utilizes the MSOW/Apogee credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
Monitors the initial, reappointment and expirables process for all AHS employed physicians, allied health professional staff, other health professional staff, delegated and community CIN providers affiliated with AHS. Responsible for ensuring compliance with regulatory bodies (Joint Commission, NCQA, CMS, federal and state), as well as medical staff bylaws, rules and regulations, policies and procedures, and delegated contracts.
Performs miscellaneous job-related duties as assigned
What You Will Need:
High school diploma or GED
Minimum 5 years of healthcare experience with 1 year directly related to hospital medical staff or managed care credentialing and/or provider enrollment.
Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis
Knowledge of medical credentialing and privileging procedures and standards.
NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing certification and secure within 1 year in the role
AS Degree in healthcare, preferred
4 years directly related to hospital medical staff or managed care credentialing and/or provider enrollment
Responsible for coordinating, monitoring, and maintaining the credentialing and re-credentialing process. Facilitates all aspects of Adventist Health Systems (AHS) credentialing, including initial appointment, reappointment, expirables process of physicians and allied health professionals, and all other providers outlined in AHS policies, or related contracts. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications. Works under the supervision of the Centralized Verification Office (CVO) Manager.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.