Position SummaryPerform day-to-day credentialing and re-credentialing activities for providers within the Credentialing Department. Performs payor enrollment and maintenance with payors on a regular basis.A' Maintain customer-focused relationships with MFA departmental contacts to ensure a smooth and efficient credentialing process.Essential Duties and Responsibilities include the following:A' To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.A' Other duties may be assigned. Credentialing & Privileging - Conduct and participate in credentialing and privileging activities (40%)Determine practitioner's eligibility for membership/participation to ensure compliance with accreditation and regulatory standards.Distribute and track all credentialing application packets requested by MFA department contacts for prospective practitioners.Utilize CAQH database to retrieve and analyze practitioner application and supporting documentation for completeness according to accreditation and regulatory standards.Inform practitioner and MFA department contacts of the application status, and resolve pending issues, including the collection of additional information.Perform processing of initial and reappointment applications for eligible practitioners to ensure compliance with accreditation and regulatory standards.Compile, evaluate, and present practitioner files for committee review to ensure compliance with accreditation and regulatory standards.Complete the enrollment application into DC Medicaid, Maryland Medicaid, Virginia Medicaid, Medicare, and Tricare for each practitioner.Ensure the provider numbers for the governmental payors are loaded in the billing system to ensure the timely release of claims to the payors.Complete the revalidation/re-enrollment application into DC Medicaid, Maryland Medicaid, Virginia Medicaid, and Medicare for each practitioner every five years.Update the medical/professional licenses that are about to expire with DC Medicaid, Maryland Medicaid, and Virginia Medicaid.Work with the billing department to make sure rejections for credentialing related reasons are addressed in a timely fashion and the charges are resubmitted for payment. Primary Source Verification - Conduct primary source verification activities (20%)Obtain and evaluate information from acceptable primary sources to ensure compliance with accreditation and regulatory standards.Identify, investigate, and report any discrepancies/adverse information obtained from practitioner application, primary source verifications, or other sources.Verify and track expired documents utilizing acceptable verification sources to ensure compliance with accreditation and regulatory standards.Perform primary source verifications of licensure, board certification, DEA/CDS certification, education/training, Medicare/Medicaid sanctions, hospital privileges, malpractice history, insurance coverage, and NPDB queries. Compliance - Comply with accreditation and regulatory standards (15%)Participate in the development, implementation, and ongoing assessment of bylaws, rules/regulations, and policies and procedures to ensure continuous compliance with accreditation and regulatory standards.Prepare documentation and participate in on site audits from delegated credentialing entities to ensure compliance with accreditation and regulatory standards.Perform ongoing monitoring and evaluate practitioner sanctions, complaints, and adverse actions to ensure compliance with accreditation and regulatory standards. Operations - Support departmental/organizational operations (25%)Meet or exceed individual productivity metrics, quality, and timeliness standards as defined by department guidelines and current workload.Maintain credentialing database (MD-Staff); track collection of NPI, Medicare, Medicaid, DEA, CSC, and state licenses; update practitioner records as appropriate.Conduct follow up with government payers to ensure application receipt and status of enrollment processing.Conduct research and resolve issues related to outstanding provider numbers from all governmental payors.Inform practitioners and stakeholders of credentialing decisions; send letters, reports, and systems updates in a timely manner.Coordinate committee meeting logistics, documentation preparation, and follow up consistent with assigned credentialing related activities.Coordinate collection of malpractice insurance certificates for new and current providers; serve as key liaison to MFA insurance administrator.Maintain adequate office supplies and complete orders for new supplies upon management approval.A' Perform miscellaneous duties as assigned including assisting Credentialing Manger with special projects.Performance Expectations and Accountability:Ability to maintain current and competent knowledge of NCQA Standards of Credentialing, as well as, MFA Credentialing Policies and Procedures.A' A' Ability to prioritize tasks, meet tight deadlines, and react to workflow and process problems.Ability to provide meaningful input and develop solutions when general standardized processes require adjustment.Ability to work independently.Ability to work in an environment of continual change with flexibility and ingenuity.Ability to conduct high degree of follow up with internal and external parties.A' Ability to escalate issues or internal process problems appropriately. A' Qualifications The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Education A' A' A' A' A' A' A' A' A' A' A' High school diploma; Bachelor's degree preferred A' Experience A' A' A' A' A' A' A' A' Minimum of two years' experience in healthcare industry; direct experience in managed care and credentialing environment. Knowledge of NCQA credentialing standards and regulatory requirements. Experience using windows software applications including, Excel &Word. Experience using CAQH Universal Provider Database strongly preferred.