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Posted By Administrator
- August-20-2007
- 12:26am
- 0 comments
- Edit
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TITLE: Credentialing Program Coordinator Delegation and Provider Data
DEPARTMENT: Office of Clinical Affairs
REPORTS TO: Manager of Credentialing
JOBCODE/GRADE/FLSA: 4675 / 11 / Exempt
Boston Medical Center HealthNet Plan (BMCHP) is a dynamic and growing managed care organization for MassHealth and Commonwealth Care recipients. Our goal is to be a provider-focused, high-quality, and culturally competent managed care plan.
JOB SUMMARY:
This position is responsible for the oversight of all credentialing delegation agreements in the network, maintenance of credentialing software data integrity, and all reporting to assure compliance with NCQA, MassHealth and state requirements and BMCHP internal processes.
KEY FUNCTIONS/RESPONSIBILITIES:
Conducts annual delegation audits at each of the delegation sites in the network. Prepares appropriate documentation prior to and after the audits. Communicates with delegated entity, develops corrective action plans and monitors compliance. Provides reports to the Credentialing Committee.
Prepares ongoing documentation for a minimum of 20 delegation agreements to include pre-delegation meeting summaries, audits, correspondence to delegates, plans for improvement, and reports from delegates. Responsible for preparation of all binders for NCQA on site survey.
Assures accuracy of data entry and maintenance in the Credentialing software, Cactus. Assures updates with provider changes are implemented within assigned timeframe. Identifies and addresses data issues including credentialing status, delegated status, and Board Certification status. Develops processes for data clean up.
Handles annual Board Certification validation project for HEDIS audit. Works with internal programmer to verify and apply appropriate specifications for Board Certification measure.
Responds to internal and external inquiries regarding delegated providers and credentialing status questions. Works with Provider Relations and Contracting staff in Regional offices to assure efficient and timely communications with delegated entities. Drafts internal processes to support delegation file processing.
Creates and distributes routine reports to support day to day operation of the department, including compliance with NCQA standards, initial application turnaround times, inventory management and staff performance reporting.
Assists with file reviews as needed.
QUALIFICATIONS:
Education and Experience:
A Bachelors degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required
A minimum of three (3) years of progressively responsible credentialing experience required.
Competencies and Attributes:
Excellent oral and written communication skills required.
Ability to provide high quality customer service.
Experience with standard Microsoft Office applications (Outlook, Word, Excel, PowerPoint) is required.
Comprehensive knowledge and experience with Cactus credentialing database preferred.
National Certified Provider Credentialing Specialist Certification preferred, but not required.
WORKING CONDITIONS AND PHYSICAL EFFORT:
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required.
No or very limited exposure to physical risk.
This position description is intended to describe the general nature and level of work of this position, and is not an exhaustive list of all responsibilities, duties, and skills required of individuals in this role.
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