CVS Credentialing Coordinator

Coordinates credentials verification and analysis activities to support appointment, reappointment and other credentialing activities to the practitioners of the medical staff of all Advocate Aurora Health hospitals, surgical clinics and health network, and external customers.

Major Responsibilities:

• Evaluates requests for applications and obtains authorization as needed. Determines appropriate action to accept or deny application requests. Initiates application process.
• Processes applications, reappointments and other credentialing events to the Medical Staff/Network, assessing practitioner information to determine the presence of potentially adverse information and determines further action required. Responsible for quality control on the content and completeness of finalized practitioner credentials files.
• Coordinates biennial review, ensuring each practitioner seeking reappointment is evaluated according to requirements by external accreditation and regulatory standards.
• Documents all work performed for credentialing events in database as part of the communication with internal customers.
• Communicates the progress, completion and findings of ongoing applications to leadership, and as appropriate to other customers. Identifies evolving issues of concern and takes appropriate action.
• Maintains credentialing database according to department policies and procedures and regulatory guidelines. Provides an electronic historical record of credentialing events within the organization.
• Responsible for investigation and documentation of practitioner credentials, utilizing specialized knowledge to obtain verification of all aspects of a practitioner's background, training and past practice. Understands credentialing requirements of both The Joint Commission and NCQA, CMS and other governmental requirements, and performs in accordance with these standards.
• Generates and maintains accurate documentation that may be reviewed and judged for acceptability by state and federal licensing agencies, external customers and may be called into a court of law to justify decision-making by Aurora entities. Manages external audits for delegated credentialing contracts, prepares and reviews files, transmits to delegate, demonstrates adherence to NCQA standards through individual credentialing records.
• Evaluates privilege requests to ensure that required supporting documentation named in privilege criteria is included.
• Deals with customer questions and complaints by Aurora Health Care caregivers, physicians, allied health practitioners and external agencies.

Licensure, Registration, and/or Certification Required:

• Credentialing Specialist, Certified Provider (CPCS) issued by the National Association Medical Staff Services (NAMSS).

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 3 years of experience in physician credentialing, medical education, a hospital environment and/or health insurance.

Knowledge, Skills & Abilities Required:

• Excellent communication, organizational and problem solving skills.
• Proficiency in the use of Microsoft Office (Excel, Access, PowerPoint and Word) and credentialing software.
• Ability to sit for extended periods.
• Ability to use a computer, enter data, and write for extended period.
• Ability to organize and professionally manage demanding workload.
• Demonstrated team player and self-motivated.
• Preferred knowledge of accrediting and regulatory agencies as related to the Medical Staff, including (but not limited to) Joint Commission, DNV, HFAP, CMS, OSHA, NCQA and State and Federal Law and other standards and regulations, and hospital and system-wide policies regarding licensed independent practitioners in the hospital setting required.
• Ability to work effectively and independently.

Physical Requirements and Working Conditions:

• Exposed to a normal office environment.
• Operates all equipment necessary to perform the job.

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This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.