Under the supervision of the Manager of DUHS CVO and the Lead Credentialing Specialist, the Credentialing Specialist is responsible for all aspects of the credentialing for all medical providers who provide patient care at Duke University Health System (DUHS), Responsible for ensuring providers are credentialed in accordance with The Joint Commission, NCQA, CMS, and AAAHC Standards for health plans, hospitals, ambulatory care centers and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of appointments, and all-time limited credentials.
Duties and Responsibilities of this Level
Processes initial and/or reappointment applications for DUHS, and any future Health System acquisitions.
Monitors applications and provide updates to applicants and documents in the credentialing system in compliance with NCQA Standards.
Compiles and maintains current and accurate data for all providers.
Verifies the legitimacy of practitioner information with the primary source of the credentials and in accordance with the accreditation regulatory standards, and state/federal laws for universities, licensing agencies, hospitals and certification bodies.
Maintains credentials database with up-to-date practitioner information, including medical license, drug enforcement administration (DEA) certificate professional liability insurance, board certifications and renewal period expiration dates.
Executes queries for the National Practitioner Data Bank (NPDB) for initial appointment and reappointments through NPDB Continuous Query in the Credentialing database.
Submits credentialing materials to the Medical Staff Office and flags any concerns for initial applications.
Ensures physician practice demographic information is compliant with health plans, agencies and other entities.
Maintains confidentiality of provider information.
Provides credentialing, re-credentialing and privileging verifications in accordance with regulatory standards, and state/federal laws.
Assists with scanning credentialing materials, if applicable.
Serves as a resource with internal and external contacts on administration of program and/or program policies and procedures.
Applies office standards, policies, procedures and authority levels when responding to questions from both internal and external customers.
Organizes and maintains resource information and job procedures pertinent to responsibilities.
Prepares a variety of documents, records, reports, etc. as needed to perform job responsibilities.
Performs other duties as assigned.
Lead Credentialing Specialist Duties and Responsibilities:
In addition to above duties as Credentialing Specialist the Lead Credentialing Specialist would be responsible for the following duties:
Monitors and maintains timeliness of all initial and re-credentialing activities. Audits initial and reappointment applications for completeness once the CVO verification has been completed by the Credentialing Specialists. If the file is deemed complete, routes the file to the appropriate Medical Staff Office in the Health System for their process to begin. If deemed incomplete, the file is returned to the Credentialing Specialist to retrieve the missing information required for completion.
Distributes and receives, assigns and tracks initial and reappointment applications, schedules, and other pertinent information regarding re-credentialing of providers for the four Duke facilities, with correctness and completeness.
Communicates with providers, office staff, department contacts, the three other Duke Entities Medical Staff Services Coordinators, etc., regarding initial and re-credentialing application status and other activities.
Assists with interpretation, explanation and following all regulatory guidelines, including medical staff bylaws, rules and regulations and policies.
Required Qualifications at this Level
High School diploma. Associate degree preferred.
Two years of experience in a credentialing office
Degrees, Licensure, and/or Certification
Certification by NAMSS (CPCS and/or CPMSM) preferred
Knowledge, Skills, and Abilities
Maintains knowledge for compliance of delegated credentialing contracts of current health plan and agency requirements in the managed care contracts for credentialed providers.
Maintains knowledge of state/federal laws, regulatory standards for accreditation purposes, and DUHS Bylaws, policies and procedures.
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
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