Senior Credentialing Specialist - Medical Staff Services

Minimum Qualifications: 

• Associate degree or equivalent.

• Five years of relevant credentialing experience in a managed care plan, Medical Staff Services, and credentialing verification office.

Preferred Qualifications:

• CPCS certification preferred.

Job Summary/Description:

This position is responsible for the performance of medical staff service activities. The Senior Credentialing Specialist works with the Manager/Director in organizing and supporting operational, financial, and personnel activities for medical/staff services, including but not limited to all aspects of the credentialing, re-credentialing, and privileging processes for all medical staff members who provide patient care, treatment, and service at UTMB Hospitals and Clinics.

• Perform other duties as assigned.

Marginal or Periodic Functions:

(Two below are most common functions/duties seen in this section.)

• Performs related duties as required.

• Adheres to internal controls and reporting structure.

Job Duties:

• Receives inquiries/complaints from patients via telephone, in person, email, web and

correspondence regarding their PBS and/or HPFS accounts.

• Through verbal and written communication, explain complex insurance information to

customers/patients.

• Verify eligibility for coverage with government programs and commercial insurance.

• Serve as liaison for patient in contacting third party payers regarding the patient’s

questions.

• Utilizing acquired knowledge of third-party payers and informational tools available, assist

patient in understanding the payer benefits and methodologies.

• Effectively communicate with clinical departments/divisions/clinics personnel or others to

assure the efficient handling of a patient inquiry from inception to completion.

• Determines if an adjustment should be made to a patient account (PBS and HPFS) and

effects adjustment if appropriate.

• Determines if a refund should be made on a patient account (PBS and HPFS) and effects

refund if appropriate.

• Review and resolve credit balance patient accounts from various work lists.

• Identify trends from review of accounts and effect changes to prevent reoccurrence of

problems.

• Identify, investigate, resolve and escalate, when necessary, payer, system or clinical

departmental billing problems.

• Using various work lists and reports, resolve patient account issues including bad

address accounts, delinquent accounts to be referred to outside collection agencies, etc.

• Contacts patients with outstanding balances by phone to attempt to secure payment for

the balance or establish a payment plan.

• Appropriately documents the patients account with the nature of the inquiry or contact

and the action taken.

• Always remain compliant with HIPAA regulations.

• Assists Manager with system testing as needed.

• Adheres to internal controls and reporting structure.

Knowledge, Skills and Abilities:

• Strong analytical skills with the ability to assess compliance, record, analyze, and interpret data into meaningful formats.

• Experience with accrediting bodies such as TJC, NCQA, URAC, CMS, TDI, or DNV.

• Effective oral and written communication skills.

• Ability to manage multiple projects efficiently and accurately.

• Excellent attention to detail. Establish work priorities—the ability to work independently and collaboratively with a team and multiple departments while taking full responsibility for tasks.

• Ability to communicate effectively and professionally with practitioners, administrators, internal and external stakeholders, and all levels of staff.

• Medical terminology knowledge.

• Facilitates maintaining a comprehensive credentialing program to ensure compliance with the Medical Staff Bylaws, Rules and Regulations, and other accrediting and regulatory agencies such as the Joint Commission, NCQA URAC, and DNV.

• Enters accurate and up-to-date data of providers into the credentialing database to include, but not limited to, demographic and personal information, education/training, licensure, DEA, liability information, board certification status, NPI numbers, and ECFMG certifications.

• Ensures timely and accurate preparation of the FPPE evaluation for providers that requested new and additional privileges.

• Provide guidance and support for all elected officers, clinical departments, and other medical leadership.

• Train medical staff credentialing staff on day-to-day activities related to credentialing and processes.

• Provides Medical Staff Committee support that includes, but is not limited to, overseeing the organization and planning of meetings for all medical staff committee business, activity, and reporting requirements, including attending, taking minutes, participating, and providing follow-up for meetings.

• Working Knowledge of related accreditation and certification requirements. Database management skills, including querying, reporting, and document generation.

Salary Range: 

Actual salary commensurate with experience or range if discussed and approved by hiring authority.