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Posted By Administrator
- August-20-2007
- 12:31am
- 0 comments
- Edit
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TITLE: Credentialing Specialist I
DEPARTMENT: Office of Clinical Affairs
REPORTS TO: Manager of Credentialing
GRADE/FLSA: 7 / Non-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:
Assists with all functions related to the credentialing and re-credentialing process for clinicians as designated by the Massachusetts Board of Registration in Medicines, NCQA, MassHealth, and Plan policies and procedures.
KEY FUNCTIONS/RESPONSIBILITIES:
Initiates the collection of all pertinent information from the provider, and verifies information through a variety of primary sources as appropriate. Communicates consistently with providers and provider office staff to obtain and verify information.
Analyzes provider files for completeness, accuracy, consistency, gaps in work history, lack of hospital privileges, relevant references, etc.
Identifies substantive issues and initiates further data collection as needed, from internal and external sources.
Compiles the information and writes summary for Medical Director and Credentialing Committee review. Reviews file with the appropriate department chairman as requested.
Maintains thorough understanding of NCQA, Mass Health and state credentialing standards.
Enters credentialing information into the Cactus database and updates as appropriate.
Meets assigned file processing quality and quantity standards.
Communicates status of files with internal and external customers.
QUALIFICATIONS:
Education and Experience:
High School Diploma or GED required. Associates degree preferred.
A minimum of two (2) years of credentialing experience in a health plan or a hospital medical staff services department.
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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