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Credentialing Specialist

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Mar 07, 2025
The Credentialing Specialist (CS) is responsible for the overall administration of the hospital(s) credentialing verification requirements for a specialized group of physicians and advanced practice providers. This entails the planning and organization of work, ensuring proper storage, formatting and integrity of this information in the enterprise-wide credentialing system, preparation of material for committee approval, workflow and documentation issues, and compliance with the internal policies and procedures. This position requires the utmost confidentiality as the CS is responsible for ensuring that provider files, are complete with sensitive information on providers, include but is not limited to, licensure issues, malpractice history, work and education history, and a criminal history record check at a minimum. Principal Duties and Responsibilities Responsible for the following steps of the credentialing process: Maintains relationships with members of CCO credentialing team, leadership team, medical staff professional team, members of the medical staff, advanced practice professional staff, and state licensing boards. All require courtesy, tact, patience, cooperation and confidentiality. Ensures the credentialing process complies with organizational as well as accrediting agencies (JC, CMS, NCQA), and Federal and State regulatory standards. Imports credentialing application 24-48 hours prior to application being submitted by the physician or advance professional practitioner. Send introduction letter to initial applicants stating the application was received, the process has started, and who is processing their application if questions arrive. Manage extremely busy workload of applications. Maintaining the complex credentialing database assuring accuracy and completeness. Accurately and timely adds the initial application data from the CCO portal to the application page, which is pulled for several internal and external reports. Review applications for clarity and completeness and accuracy of data in accordance with policies and procedures and time frames. Coordinates, reviews, analysis, and monitors the practitioner initial and reappointment application, and accompanying documents, for credentialing for all Physicians and Advance Practitioner Providers applicants. Assume responsibility for the entire verification process. Managing initial and reappointments applications for a wide verity of providers including promotions, internship, residency, fellowship, temporary privileges, promotions, and credentialing by proxy applications. Initiation the credentialing verification process, verifying competence, relevant board certifications, health care affiliations, professional references, licensure and certifications, MCSR and DEA certificates, malpractice coverage and privileges the applicant is requesting in accordance with policies and procedures and time frames. Conducts follow-up on non-returned documents or missing information. Identifies issues that require additional investigation, and seek necessary resources or information, to solve any problems that arise in the credentialing process. Validate and provide timely resolution for any discrepancies discovered during the process of the application. Requests confidential and sensitive information from the provider regarding claims, board complaints or other delegate. Identify any "Red Flag" issues. Verifies all expirable licensure and certifications for all states where items were acquired. Timely import obtained documents or verifications to the providers file. Compare the verification responses with the information provided by applicant to ensure information matches. Serves as a liaison between the applicant and the Medical Staff Specialist. Interacting with other internal/external customers as it relates to the applicants related issues and concerns. Obtain all required certifications required for requested privileges Inform CCO Credentialing team leads of the status of the application and any potential problems identified during the verification process in accordance with established procedures Manages deadlines as appropriate. Ensure the verification process is completed within established time frames, and prior to the established expiration date or anticipated start date. Presents reviewed and completed credentialing application to the Medical Staff Specialists to provide to the department chair, credentials committee, and medical executive committee for review and approval. Make recommendations for changes in the departmental procedures to accomplish the goals as necessary. Data management, administrative responsibilities: Maintains an electronic record for all practitioners within the credentialing database giving attention to operational concerns and the need for others to retrieve the same records. Responsible for notifying manager when a policy or procedure is found to be in need of revision due to changes in laws/regulations, inaccurate, or unable to be accomplished as written. Maintains integrity of electronic, specialized database, which includes the importing of practitioner information in accordance with departmental policies and procedures. Utilizes appropriate database tracking reports to ensure accuracy and thoroughness of data entry documentation. Document interactions with internal and external customers as appropriate within the appropriate fields of the credentialing database. Assists with the development and revision of the credentialing and audit workflows within the credentialing database. Training and development: Maintains competency on vendor database via participation in online education learning modules and monthly skills related webinars Maintains competency on nationally recognized credentialing related initiatives through participation with NAMSS and MAMSS, journal articles, and other industry related news. Participates in the orientation of new staff members, as assigned. Use the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk; and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration Other duties as assigned High school diploma or equivalent. Associate's or Bachelor's Degree in a related field preferred. Three to five years experience in credentialing services or related field CPCS preferred Skills Abilities and Comeptencies* Strong communication, problem solving, and analytical skills required. Working knowledge of general office practices and software applications and database management. Demonstrated understanding of credentialing policies and procedures and training program requirements as established by the CCO, as well as accreditation and regulatory requirements relating to the medical staff. Organizational skills required to handle high data flow and to prioritize tasks in order to meet cyclical deadlines. Ability to manage demanding workload; self-motivated; able to carry out responsibilities with minimum supervision. Analytical skills necessary to determine whether correct and complete information was provided on applications. Able to concentrate on tasks, paying meticulous attention to detail regardless of distractions. Possesses ability to manage specialized database, including production of reports covering the area of responsibility. Adheres to professional confidentiality standards in accordance with legal, ethical, and departmental policies. Handles sensitive and confidential situations/information, with a high degree of tact and diplomacy. Communicates effectively and professionally with applicants or colleagues by telephone or in person. Possess strong interpersonal skills to effectively communicate with cross functional teams including staff at all levels of the organization Ability to successfully negotiate and collaborate with others of different skill sets, backgrounds an levels within and external to the organization Strong problem solving and negotiation skills Requires minimal direction from leadership and possesses the ability to learn quickly Additional Job Description Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.