Coordinates and conducts thorough credentialing which ensures that every physician and medical associate/assistant, who provides ambulatory and inpatient services at BC facilities, is fully trained and qualified to provide the treatments and procedures requested. Provides administrative oversight of BC-practitioner licensing, board certifications privileges at other facilities, and maintenance of credentialing-related records required for all affiliations and managed care payer contracts.


ESSENTIAL JOB FUNCTIONS
• Coordinates the credentialing process of physicians and other practitioners who provide patient care in BC facilities and are members of provider panels for third-party payers. Credentials and re-credentials all practitioners who utilize hospital facilities and provide ambulatory patient care in BC facilities. Analyzes information provided by applicants and individuals/entities who verify applicant's qualifications, and ensures that these functions are carried out in the time period required. Makes decisions on how and when the following are done based on Medical Staff Services policies and Medical Staff Bylaws: initial verifications of qualifications and clinical competency; biennial re-credentialing and privileging; queries to all required national databanks, licensing boards, and certification boards; review of new applicants and reappointments by MSS Manager; communications to individuals and committees responsible for credentialing decisions; ongoing individual compliance to medical staff requirements; and maintenance of all computer databases and physical records containing these elements.
• Responsible for carrying out credentialing processes in compliance with BC medical staff bylaws, legal requirements, accrediting agencies, and third-party payer contracts. Demonstrates compliance to BC management, physician leadership, accreditors, and auditors.
• Acts as an advocate and a resource to BC Leadership and physicians, assisting with orientation of new providers, communicating and interpreting by-laws, policies, procedures and methods; communicating preliminary findings on applications and making recommendations for the need for further clarification and/or investigation.
• Assists with professional services and resources for BC practitioners (including licensing, certifications, clinical privileges held at other facilities, CME documentation), and independently implements processes which ensure well-organized service and record keeping. Acts as a resource to Medical Staff Secretary on performing tasks associated with professional services. Develops a rapport with individual practitioners, managers, physician leadership, and external customers and resources to facilitate efficient operations and information management.
• Provides guidance and support to contracted credentialing verification services provided by Medical Staff Services, ensuring that the processes are scrutinized for compliance with National Committee Quality Assurance (NCQA) standards and national standards relating to credentialing verification organizations.
• Assists with the development of departmental and hospital policies and procedures involving the credentialing process by delineating actual practices.
• Develops and maintains medical staff databases. Responsible for updating and maintaining medical staff information systems. Coordinates installation of system upgrades, development needs and problem resolution with vendor. Acts as a system expert and resource for the Medical staff information system and database. Creates and develops a variety of adhoc reports for a variety of internal and external customers. Compiles and analyzes data to prepare information and responses for regulatory compliance reports, auditors, accreditation surveys and other special requests. Responsible for maintaining records and information in accordance with legal and retention requirements.
• Provides support and backup for Medical Staff Services functions including coordination and coverage of meetings and projects, as delegated.
• Utilizes performance improvement principles to assess and improve quality.
• Identifies need and sets goals for own growth and development; meets all mandatory organizational and departmental requirements. Seeks education and networking relationships that enhance knowledge and resources to ensure good practices, quality improvement, and compliance with national standards.
• Maintains competency in all organizational, departmental and outside agency safety standards relevant to job performance.
Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.


KNOWLEDGE OF / SKILLS / ABILITIES / COMPLEXITIES AND DIFFICULTIES
• Principles of healthcare credentialing by industry and national standards
• Credentialing standards guiding the provision of services as a Credentialing Verification Organization Network and other delegated credentialing contracts
• Joint Commission Accreditation Hospital Organizations (JCAHO) and National Committee Quality Assurance (NCQA) accreditation standards relating to medical staff organization, credentialing and re-credentialing; privileging; and the responsibility of Credentialing Verification Organizations (preferred)
• Legal principles of credentialing involving professional liability insurance, peer review and discovery, and Health Care Quality Improvement Act of 1986 (preferred)
• Personal computers, hardware and software
• Medical terminology
• Credentialing terminology and managed care terminology (preferred)
• Information management and security
• Organizing and preparing for meetings, writing minutes, reporting and follow-up
• Office practices and organization
• Code of Business Conduct
• Confidentiality


SKILL IN:
• Professional communication skills, both verbal and written
• Microsoft Office programs (i.e. Word and Excel), preferred
• Utilization of database software and modem transmissions
• Operation of standard office equipment
• Prioritizing work, based on scheduled events and deadlines


ABILITY TO:
• Incorporate cultural diversity and age appropriate care into all aspects of communication and patient care; scope of services provided will primarily encompass age groups ranging from adult through geriatric
• Analyze information received and compare it to BC credentialing standards
• Communicate the category rating of an application in order to determine the credentialing track followed
• Facilitate credentialing audits
• Communicate clearly and effectively, both verbal and written
• Establish and maintain collaborative relationships
• Work with frequent interruptions and unexpected requests
• Read and interpret complex legal correspondence and documents, including the Medical Staff Bylaws
• Concentrate on detailed information and a variety of projects simultaneously
• Work independently with minimal supervision
• Present a professional appearance and demeanor when dealing with difficult situations
• Type with speed and accuracy at 60 WPM


COMPLEXITY & DIFFICULTY:
• This position is characterized by frequent demanding interactions.
• The highest degree of confidentiality and discretion is imperative when interacting with external entities and regulatory agencies. Inappropriate communications or dissemination of information can result in significant financial/legal damages to BC and/or physicians.
• Poorly kept, incomplete, inaccurate records, or non-compliance with credentialing policies can result in loss of or lowered facility accreditation status (i.e, JCAHO and NCQA).
• Credentialing/privileging functions for over 650 practitioners; professional services for approximately 220 BC practitioners; medical staff organization includes approximately 400 physicians and 150 complementary/alternative practitioners.
• Inappropriate handling of applicants could result in legal action and/or grievances being filed.
• Failure to adhere to credentialing standards and requirements could negatively impact patient safety and the quality of patient care.


MINIMUM QUALIFICATIONS
Education
• High School or GED
• Five years progressively responsible administrative/clerical experience, preferably in a health care environment


Certifications
• Certification by the National Association of Medical Staff Services (NAMSS) as a Certified Provider Credentialing Specialist (CPCS), preferred