Nova Medical Centers

  • Credentialing Specialist

    Job Locations US-TX-Houston
    Posted Date 2 weeks ago(7/31/2018 2:05 PM)
    # of Openings
  • Overview



    The Credentialing Specialist is responsible for supporting the credentialing program which includes but not limited to ensuring the quality of credentialing and re-credentialing files of employed providers in accordance with NCQA guidelines.  The Credentialing Specialist is also responsible for maintaining internal quality standards, supporting the Credentialing Committee program and coordinating credentialing activities.  In addition, Credentialing Specialist will assist in credentialing, network and provider relations activities that will support the goals of creating efficiencies and streamlining work flow processes in the department. 


    •Processes credentialing/re-credentialing files according to Nova Medical Centers’ standards for committee review adhering to NCQA/state regulatory requirements.
    •Responds to inquiries from interdepartment stakeholders on credentialing status.
    •Ensures the timely notification of provider changes to medical staff and other interdepartment stakeholders
    •Ensures timely and professional communication with providers, documents interactions and follow ups as required to ensure timely file completion
    •Ensures monthly maintenance of files to ensure compliance, i.e. licenses, DEA, malpractice
    •Tracks and monitors non-responsive providers.
    •Maintains confidentiality and security of provider files.
    •Fields, logs and tracks complaints and reports them to committee for review.
    •Completes assigned projects within agreed upon timeframes
    •Ensures files ready for committee review meet accuracy for completeness
    •Assists the SVP, Network and Payor Strategy in auditing credentialing and re-credentialing files for committee presentation.
    •Ensures all outstanding issues are resolved prior to committee review/Obtains information from practitioners tabled/pended from previous meetings
    •Knowledge and experience with HIPAA Compliance
    •Prepares list of provider credentialing/re-credentialing files for submission to Chief Medical Officer for “Clean File” or Credentialing Committee review and approval
    •Coordinates the interdepartmental credentialing committee meetings by contacting the committee members and setting up the time, date and place of meeting.
    •Prepares and collates committee packets as outlined in the committee agenda
    •Attends committee meetings as assigned by the SVP, Network and Payor Strategy
    •All other job related duties as it relates to the job function or as delegated by the management team.


    •Minimum 3-5 years of experience Credentialing experience in physician Credentialing department
    •Certified Provider Credentialing Specialist (CPCS) required
    •Familiarity with credentialing database software, such as MD Staff
    •Knowledge of NCQA credentialing requirements
    •Ability to process high volume initial and recredentialing files
    •Detail oriented, good organizational skills, and ability to manage competing priorities.
    •Proficient in Microsoft Word, Excel, Outlook, and Internet Explorer.
    •Basic medical credentialing knowledge a plus.


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