Credentialing Specialist - Tucson, AZ (Corporate-Bonita)

General Summary: Responsible for initiating, coordinating, monitoring, and managing credentialing processes with contracted health plans. Facilitates all aspects of practitioner, organizational and facility credentialing, in accordance with state, federal and health plan requirements. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statutes and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing software system and management of related applications.

JOB RESPONSIBILITIES:

• Ensures licensed independent practitioners, medical providers, therapeutic foster families, and site locations.
• therapeutic foster families, and site locations meet credentialing requirements as set forth by each contracted health plan, including AHCCCS, commercial and Medicare health plans.
• Collaborates with program manager and HR to compile and submit credentialing documents and applications necessary to implement the credentialing process.
• Performs initial review of credentialing documents to ensure practitioner is in good standing with CAQH, AHCCCS and licensing board(s).
• Identifies issues/discrepancies that require additional review and follow-up.
• Completes requests and/or updates for Medicare, AHCCCS IDs, CAQH, NPI and other steps needed for the credentialing process.
• Performs re-credentialing activities upon request and within time frames specified by the health plan.
• Manages and maintains credentialing files and/or profiles as needed to ensure provider information is accurate and up to date.
• Manages, tracks and monitors provider credentialing/re-credentialing applications from submission to completion.
• Maintains credentialing software with current provider and site information.
• Responds to inquiries from healthcare organizations, interfaces with internal and external customers, as needed.
• Creates and distributes credentialing status reports on a regular basis.
• Performs reconciliation and maintenance activities of health plan directories/rosters as required by health plan.
• Performs on-going credentialing audits; conducts internal file audits.
• Performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
• Manages the initial, reappointment and expirable process for all Behavioral Health Medical Professionals and Independently Licensed Professional staff, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
• Professionals and Independently Licensed Professional staff, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
• Responsible for following all policies, procedures, and controls established by the organization, the HIPAA Privacy Officer, and/or the HIPAA Security Officer regarding access to, protection of, of, and the use of the PHI.

QUALIFICATIONS:

Education- High School Diploma or GED required.

Experience - At least 3 (three) years of experience in a health care environment performing provider enrollment, credentialing and/or some contracting tasks, preferably with a behavioral health agency or health plan.

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.

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