ESSENTIAL DUTIES OR RESPONSIBILITIES – (The below listed duties are not all inclusive. This position must also perform other duties as assigned.):

• Reviews provider applications for completeness according to company policy and client criteria.
• Confirms all required verification and data collection elements are received.
• Confirms all information received from sources matches data in CVO database and on the provider application
• Completes all electronic verifications.  Identifies “in-error” query transactions, obtains/corrects the applicable provider data, and re-requests the transaction.
• Processes, posts, and scans verification documents.
• Expedites requests for verification according to client criteria and COL policy.
• Identifies possible adverse issues that require additional investigation and evaluation, validates discrepancies and ensure appropriate follow up.
• Performs quality audit of 100% of files prior to closure and return to client.
• Interacts with clients regarding any quality issues.
• Tracks history of provider files.
• Maintains familiarity with interpretation and compliance with the appropriate accrediting agencies, to include, but not limited to NCQA and TJC standards as they relate to client contract terms.
• Assists with preparation and compliance with biannual audits and job related projects as requested.

JOB SPECIFICATIONS: What specialized, technical, or practical knowledge, skills, experience or abilities are needed to perform the job.  (Include degrees, certificates, licenses, or other bona fide job qualifications.)

A.         KNOWLEDGE/EDUCATION AND EXPERIENCE REQUIRED:

1.         CPCS or CPMSM Certification

2.         2 years of experience in a complex administrative position involving credentialing or verification responsibilities in a healthcare setting.

3.         Familiarity with NCQA and TJC standards as they relate to credentialing.

4.         Knowledge of Medical terminology.

B.         SKILLS REQUIRED (manual, verbal or mental manipulation of data or things):

1.         Excellent attention to detail.

2.         Excellent organizational, analytical, and both oral and written communication skills.

C.        ABILITIES REQUIRED (work characteristics, behaviors, leadership abilities, etc.):

1.         Ability to work independently and exercise independent judgement.

2.         Ability to understand and apply policies and procedures and regulatory standards associated with medical credentialing.

3.         Extensive phone and computer usage.

4.         Could lift up to 20 lbs.

5.         This position is primarily sedentary in a normal office environment.