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Posted By Administrator
- August-20-2007
- 12:30am
- 0 comments
- Edit
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TITLE: Credentialing Program Coordinator Quality & Compliance
DEPARTMENT: Office of Clinical Affairs
REPORTS TO: Manager of Credentialing
JOBCODE/GRADE/FLSA: 4685 / 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 quality review of all files prior to Committee submission, quarterly file audits to assure NCQA, MassHealth and state requirements, implementation of the Committee process and coordination of all Committee materials, ongoing monitoring of clinicians and facilities in the network and oversight of the provider appeals process.
KEY FUNCTIONS/RESPONSIBILITIES:
Reviews all initial and re-credentialing files processed by the Credentialing staff. Documents compliance with all regulations. Identifies issues of non-compliance for the supervisors review with staff.
Conducts quarterly audits for appropriate number of files. Prepares documentation for Credentialing Committee review and approval.
Conducts mock audits semi-annually to assure NCQA compliance in conjunction with BMCHP quality staff.
Oversees Credentialing Committee Process. Prepares files for Medical Director review, prepares all documents for the Committee, including individual file summaries, agenda, credentialing lists for approval, special and previously tabled issues.
Handles all post Committee responsibilities. Notifies Clinicians of Board certification waivers. Conducts follow up process for granted waivers to assure compliance with Mass Health requirements.
Conducts ongoing monitoring for all clinicians in the network. Gathers, documents, and takes action upon receipt of information from Mass Health, State Licensing Boards including the Massachusetts Board of Registration in Medicine, internal member concerns and clinical occurrences. Prepares automatic and administrative termination lists, special issues of disciplinary actions, and the ongoing monitoring semi-annual report for Credentialing Committee review.
Notifies internal and external constituents with termination information.
Responsible for preparing correspondence, handling communication with providers, and creating files for appeals in compliance with the BMCHP Policy for Appeals.
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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