Quality Assurance Credentialing Auditor
Location: Steward Health Care
Posted Date: 7/14/2021
POSITION SUMMARY: (Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?) The Quality Assurance Credentialing Auditor is responsible for auditing all complete credentialing applications and to build sound, effective and efficient audit processes. We are looking for a highly qualified person who can excel and innovate in this role. The role will combine responsibilities for process improvements around credentialing. The position will report to the Initial Appointment manager with oversight and direction by the Director of the Credentialing Verification Office (CVO).
KEY RESPONSIBILITIES: (Use bullets for specific responsibilities)
* Completes initial and ongoing quality audits of Credentialing Coordinators, while providing constructive feedback and education to individual associates.
* Monitors performance and productivity of all Credentialing Coordinators.
* Audits 100% of credentialing and re-credentialing files submitted by Credentialing Coordinators to ensure compliance with relevant accreditation and regulatory standards and internal policies and procedures and the data entered into the Credentialing database.
* Analyze credentialing files for completeness, accuracy, consistency, gaps in work history, relevant references, etc. Identify issues and initiate further data collection as needed.
* Track and trend audit findings and administer appropriate staff education and coaching and adherence to NCQA policies
* Manage multiple concurrent audits, plan audits and related projects, make judgments around objectives and scope and ensure effective and efficient execution.
* Review and maintain all audit tools to comply with NCQA, TJC, DNV, CMS, Federal and State requirements.
* Conduct pre-delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
* Coordinates the credentialing and re-credentialing process for assigned providers.
* Collects and maintains all pertinent information from the provider. Communicates consistently with providers and provider office staff in a timely and effective manner to obtain required documents in accordance with processing guidelines.
* Verify all credentialing elements, including but not limited to, education, training, board certification, work history, licensure and certifications, malpractice coverage through a variety of primary sources as appropriate per NCQA, TJC, DNV, CMS, Federal and State standards.
* Enters data accurately and completely in the credentialing software.
* Assist in the formulation of staff training guides, policies and procedures, understand and interpret policies and regulations.
* All other duties as required and assigned to ensure the CVO operations are successful. CORE VALUES Compassion Accountability Respect Excellence
REQUIRED KNOWLEDGE & SKILLS: (Examples: Ability to work independently and take initiative; Good judgment and problem solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality) * MUST HAVE MEDICAL STAFF OFFICE
EXPERIENCE * Excellent communication skills: written and verbal with all internal/external customers. * Strong time management and organizational skills. * Extensive knowledge of credentialing and re-credentialing practices relevant to accreditation and regulatory standards. Experience with NCQA, TJC, DNV, CMS, Federal regulations. * Ability to handle conflict and difficult situations. * Detail oriented with exceptional accuracy.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER: Education: Bachelor's degree or equivalent education and experience Experience: * Three or more years of credentialing experience in a medical staff services department or centralized verification office desired. * Experience with Initial and Recredentialing file processing according to NCQA, DNV and TJC standards. * National Certified Provider Credentialing Specialist Certification preferred. * Previous supervisory experience a plus. *This position is tele-commute and applicant must provide own high speed internet. All other equipment is provided. Applicants must reside in one of the following states to be considered: MA, AR, AZ, FL, GA, KS, KY, LA, MO, NC, NJ, NM, NY, OH, PA, SC, TN, TX, UT, WI.