Credentialing Specialist jobs in Eau Claire, WI

Schedule Weekly Hours:

The Credentialing Specialist coordinates processes related to credentialing, privileging, and practitioner quality and competence, so as to provide Gundersen Health System medical leadership, and/or leadership of its contracted entities, with valuable information for the evaluation of practitioner performance.

Major Responsibilities:

1. Coordinates the processing of all initial and reappointment provider applications in accordance with various regulatory requirements including, JC, NCQA, federal and state regulations, CMS and other governmental payers, as well as Gundersen Health System Medical Staff Bylaws, to include the Medical Staff Bylaws of each Gundersen Health System regional center, policies and procedures and obligations of the entities which contract with Credentialing Services.

2. Analyzes and evaluates the primary source verification data and documents in accordance with Gundersen Health System and outside regulatory requirements and to determine quality and adequacy. Researches and pursues additional information if necessary to ensure good decision-making.

3. Understand and interpret regulatory standards for Joint Commission, NCQA, CMS, federal and state regulations.

4. Meets with Department Chairs, Credentials Committee members and Executive Committee members to present information and review reports.

5. Facilitates medical staff leadership review of each practitioner by preparing and presenting reports of primary source data, detailed physician summaries, privileging criteria/competence information, and by identifying any potentially adverse information.

6. Manages data quality and integrity and maintains an up-to-date database program to store and track information and prepare customized reports as needed in the evaluation of practitioners, as requested by others, and for maintenance of data integrity.

7. Works collaboratively with Department Chairs to develop and maintain Focused Professional Practice Evaluation standards and criteria. Also works collaboratively with Department Chairs to develop and maintain Ongoing Professional Practice Evaluation standards and criteria.

8. Coordinates the electronic expirables management system to ensure renewal of all medical and associate staff applicable state licenses, DEA's, malpractice insurance, certifications and other required expirables. Assists medical and associate staff in renewal process as needed.

9. Meets with, participates in and prepares reports for the JC accreditation survey process, the NCQA survey process, CMS and State audits and in the auditing process of those who delegate the primary source verification process to Gundersen Lutheran Credentialing Services.

10. Coordinates and provides support to the privilege delineation process of Gundersen Health System and all of its Regional Affiliates for both the inpatient and ambulatory settings in accordance with various regulatory requirements, such as JC and CMS, and the Gundersen Health System Medical Staff Bylaws, policies and procedures. Works collaboratively with Department Chairs, the Credentials Committee, Executive Committee, Regional Gundersen Health System medical leadership, Compliance and Legal to develop and maintain privileging criteria.

11. Analyze and evaluate privilege criteria data and documents.

12. Collaborates with area clinics, hospitals, credentialing offices and human resource departments to assure efficient coordination of Gundersen Health System practitioner credentialing for outreach and telemedicine work. Supports outreach activities of Gundersen Health System medical and associate staff by expediting the application process at other facilities, including assisting with application forms and providing necessary documentation.

13. Collaboratively works with Managed Care to comply with, oversee and conduct the review of NCQA, CMS, and state requirements related to provider credentialing, network participation standards, and network provider standards for the delegated credentialing contracts.

14. Performs other job-related responsibilities as requested.

Education and Learning:

REQUIRED Associate degree in Healthcare or Legal or Business

DESIRED Bachelor's degree in Healthcare or Legal or Business

Work Experience:

REQUIRED 2 years of related healthcare or legal experience.

DESIRED 1 year of knowledge of the principles and practices of physician credentialing and privileging and provider enrollment. Experience in working with sensitive and highly confidential information. Experience with the heightened understanding of the medical staff organizational structure.

License and Certifications:

DESIRED Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Staff Management (CPMSM)

Age Specific Population Served:

Nonage Specific (N/A)

OSHA Category:

Category III - No employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.

Environmental Conditions:

Not substantially exposed to adverse environmental conditions (as in typical office or administrative work).

Physical Requirements/Demands Of The Position:

Sitting Frequently (34-66% or 5.5 hours)

Reaching - Below Shoulder Frequently (34-66% or 5.5 hours)

Repetitive Actions - Pinch Forces Frequently (34-66% or 5.5 hours) Pounds of force 0-25

Repetitive Actions - Fine Manipulation Frequently (34-66% or 5.5 hours)

If you need assistance with any portion of the application or have questions about the position, please contact or call 608-775-0267

Equal Opportunity Employer