Credentialing Specialist - Remote Must Reside in North Carolina

General Description of the Job Class

Under the supervision of the Manager of DUHS CVO and the Lead Credentialing Specialist, the Credentialing Specialist is responsible for all aspects of the credentialing for all medical providers who provide patient care at Duke University Health System (DUHS), Responsible for ensuring providers are credentialed in accordance with The Joint Commission, NCQA, CMS, and AAAHC Standards for health plans, hospitals, ambulatory care centers, and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of appointments and all-time limited credentials.

Duties and Responsibilities of this Level

• Processes Initial applications for DUHS, ensuring compliance with regulatory requirements.
• Obtains verification from primary sources for all regulatory requirements and monitors all applications assigned credentialing to provide updates to applicants and documents in the credentialing system in compliance with regulatory standards.
• Researches and maintains current and accurate data for all providers for the Health System within the Credentialing database.
• Verifies the legitimacy of practitioner information with the primary source of the credentials and in accordance with the accreditation regulatory standards, and state/federal laws for universities, licensing agencies, hospitals, and certification bodies.
• Maintains a complex credentialing database with up-to-date practitioner information, including medical license, drug enforcement administration (DEA) certificate professional liability insurance, board certifications, and renewal period expiration dates.
• Executes queries for the National Practitioner Data Bank (NPDB) for initial applications through NPDB Continuous Query in the Credentialing database.
• Ensures that any reports received through the queries are flagged for the Medical Staff Offices
• Presents complete Health System applications with credentialing verification materials and flags any concerns for initial applications for the Medical Staff Offices to act upon.
• Ensures data integrity within the Credentialing database for physician practice demographic information and ensures it is compliant with health plans, agencies, and other entities.
• Analyzes complex information in the credentialing application process, ensuring there are no time gaps, we are obtaining the documentation required for compliance with policies, regulatory standards, and State and Federal laws.
• Maintains confidentiality of all provider information within our credentialing database, as well as documentation gathered through the credentialing process.
• Provides credentialing and privileging verifications in accordance with regulatory standards, and state/federal laws.
• Composes, proofreads, or edits formal correspondence, memoranda, and short reports for internal and external circulations. Assembles attachments and corresponding materials. Reviews outgoing materials for completeness, dates, and signatures.
• Serves as a credentialing subject matter expert with internal and external contacts on the administration of the program and/or program policies and procedures.
• Applies office standards, policies, procedures, and authority levels when responding to questions from both internal and external customers.
• Organizes and maintains resource information and job procedures pertinent to responsibilities.
• Prepares a variety of documents, records, reports, etc. as needed to perform job responsibilities.
• Performs other duties as assigned.

Knowledge, Skills and Abilities

Maintains knowledge, as the Subject Matter Expert for compliance of policies and procedures. delegated credentialing contracts of current health plan and agency requirements in the managed care contracts for credentialed providers. Maintains knowledge, as the Subject Matter Expert of state/federal laws, regulatory standards for accreditation purposes, and DUHS Bylaws,

Minimum Qualifications

Education

Work requires analytical, communications and organizational skills generally acquired through completion of a bachelor's degree program. In lieu of bachelor's degree, four years relevant experience in Managed Care or Medical Staff Credentialing/Privileging (in addition to the experience requirement for the role)

Experience

One year of experience in a Medical Staff/Managed Care credentialing office. Lead Credentialing Specialist Experience: Three years of experience in a Medical Staff/Managed Care credentialing office.

Degrees, Licensures, Certifications

Certification by NAMSS (CPCS and/or CPMSM) preferred

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.