Credentialing & Compliance Specialist
Supervisor: Practice Manager
Compensation: $23/hr, Generous and Comprehensive Benefits
Hours: FTE 40 hours/week
The Credentialing and Compliance Specialist coordinates and performs all credentialing functions, including coordinating with appropriate insurance plans, submitting & re-submitting provider applications, and managers compliance requirements as outlined below. The Credentialing and Compliance Specialist works independently with minimal supervision.
This position description is not intended to be an all-inclusive list of responsibilities, skills, or working conditions associated with this position. Management reserves the right to modify, and/or remove duties as necessary.
Credentialing Specialist Functions:
- Manages the PMHW credentialing process for all clinical providers in accordance with accreditation standards.
- Manages the credentialing database and associated modules, ensuring accuracy of data and reporting to downstream systems.
- Coordinates the management of the electronic credentials application, to ensure distribution, receipt, processing, and timely delivery to health system entities.
- Coordinates the management of the expirables process to ensure all clinical provider licenses and certificates remain current, ensuring appropriate notification prior to expiration.
- Monitors and reports turnaround times for processing of credentials applications, with continued focus on delivery of a high quality product, with the greatest efficiency, in the least amount of time.
- Prepares for and coordinates credentialing audits in compliance with the credentialing contracts.
- Functions as primary PMHW credentials contact for all internal and external inquiries; develops and maintains positive working relationships with insurance partners.
- Additional tasks or duties as directed or assigned.
Compliance Specialist Functions:
- Confirm Quarterly & Semi Annual Reviews are Competed for All Staff in Compliance with OHA Requirements
- HIPAA Compliance Training Compliance
- HIPAA compliance
- Fraud, Waste & Abuse officer
- Confirming All Onboarding Training and Annual Trainings Are Completed by Staff
- Initiate and Manage Quarterly Quality Improvement & Quality Assurance Meetings & Related Reporting
- Initiate Chart Reviews for Therapists and Confirm Completion By Directors and Therapists
- Confirm Chart Peer Chart Reviews for Psychiatric Practitioners are Occuring with Compliance
- Manage Bring Your Own Device Registration and Closure
- Additional Regulatory & Compliance Responsibilities as Assigned
Employee must show the ability to:
- Communicate professionally and effectively with patients and providers
- Answer electronic phone systems with excellent phone demeanor; warm/friendly tone, articulate, provide intelligible responses to patient questions or concerns
- Demonstrate a strong understanding of HIPAA policies and regulations
- Demonstrate strong attention to detail and organization
- Show compassion: Employees sees people during moments of trauma or crisis, when they and their family are vulnerable or in pain
- Demonstrate patience: Being patient with people who may have trouble communicating or understanding what is happening is important
- Ability to work effectively as a team member with medical and mental health professionals as well as administrative support staff.
- Ability to sort and file materials correctly by alphabetic or numeric systems.
- Ability to interpret and understand insurance benefits and reimbursement.
- Ability to flexibly respond to changing demands.
- Ability to organize and prioritize tasks effectively.
- Ability to communicate clearly.
- Ability to work with minimal supervision.
- Ability to establish and maintain effective working relationships with patients, employees, and the public.
Employee must show the knowledge of:
- Knowledge of the practice’s policies and procedures.
- Knowledge of or willingness to learn industry-specific terminology and insurance practices.
- Knowledge of grammar, spelling, and punctuation for effective and appropriate communication.
- Knowledge of web-based computer programs and applications in an Apple/Mac environment
Employee must show skills in:
- Skill in using office equipment and in handling paperwork and filing adequately.
- Skill in handling incoming phone calls and triaging appropriately.
- Skill in written and verbal communication.
- Skill in gathering, interpreting, and reporting insurance information.
Equipment Operated: Standard office equipment, including computers, fax machines, copiers, printers, telephones, etc.
Work Environment: When working from a PMHW office, the position is in a well-lighted office environment. Varied activities including sitting, standing, walking, reaching, bending, and lifting.
Mental and Physical Requirements: Involves sitting approximately 90 percent of the day, walking or standing the remainder. Ability to tolerate mental and emotional distress as an anticipated aspect of the position. May require working under stressful conditions.
This description is intended to provide only the basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities, and working conditions may change as the practice’s needs evolve. Regular and predictable attendance is an essential function of every job.