"Med Staff/Credentialing Spec"

Provides a full range of professional services for credentialing, recredentialing, verifying licensing and certifications, monitoring sanctions, assessing competency, and processing privileging, as appropriate, by applying expert knowledge, expertise, and experience. Acting as a specialist in the complex Michigan Medicine credentialing process has the authority to make independent decisions on matters of significance within the scope of responsibilities through analyzing, comparing, and evaluating various courses of action.

Accountability for completion of initial appointment/reappointment, credentialing, and privileging following the strict requirements of Centers for Medicare and Medicaid (CMS), The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), Accreditation Commission for Health Care (ACHC), and Utilization Review and Accreditation Commission/American Accreditation Health Care Commission (URAC) to ensure the safety of our patients and safeguard Michigan Medicine against loss of accreditation, malpractice claims, and claims of negligent credentialing.

• Completes evaluation of application to determine applicant's initial eligibility for membership/participation. Analyze application and supporting documents for completeness.
• Identifies red flags during the credentialing and privileging process with authority to halt the process until the issue has been resolved, and is empowered, using strong analytical skills and judgment, to resolve locally or determine if the issue should be escalated. The credentialing specialist autonomously conducts the final analysis thoroughly before deeming the credentialing packet as complete and ready for committee review and board approval.
• Conducts all primary source verification necessary to complete the credentialing and privileging process, maintaining standards in accordance with policies and procedures, rules, regulations, and accreditation requirements. Through delegated credentialing contracts, the credentialing specialist completes this work on behalf of each contracted plan, leveraging the contracts to expedite enrollment and reimbursement.
• Using knowledge, creativity, and ingenuity, identifies and implements ideas for process improvement using continuous improvement tools and strategies, wherever possible, keeping within the confines of the rules, regulations, and accreditation requirements to develop a more efficient process while still providing a safeguard to the institution.
• Applies broad knowledge and ability in the interpretation and dissemination of policies, procedures, and processes/rules/regulations/law changes, concerning credentialing and recredentialing for practitioners at Michigan Medicine. Will act in an advisory capacity when questions or concerns about policies and procedures are raised.
• Ensure regulatory and accreditation readiness with contracted health plans, the Joint Commission, CMS, and the State of Michigan by preparing and analyzing credentialing records to affirm all requirements are met.
• Maintains the confidentiality of credential information, exercising caution and discretion in responding to inquiries for information.
• Maintains and protects the integrity of the credentialing database as the source of truth for privileged provider information throughout the AMC health system's various IT systems, such as the electronic health record, online provider directory, and billing system. Ensures database accuracy so that Provider Enrollment can complete health plan enrollment.
• Management and maintenance of expirables such as licenses, certifications, and other credentials to maintain compliance with state law, policies, and procedures.
• Clearly and accurately presents complicated and thorough information regarding credentialing, recredentialing, and privileging to the clinical departments, providers, and institutional stakeholders.
• Responds to inquiries and complaints regarding matters of a sensitive or confidential nature, exercising initiative, independent judgment, and diplomacy, with an excellent customer service-oriented attitude.
• Duties as assigned.

Required Qualifications:

• Bachelor's degree or equivalent combination of education and experience
• Knowledge of accreditation and regulatory requirements for credentialing and privileging.
• 1-2 years experience in a credentialing role.
• Continuous Healthcare Improvement training within 3 months of hire.
• Demonstrated excellent interpersonal, problem-solving, and communication skills, both written and oral.
• Ability to make independent decisions on matters of significance using analytical skills and sound judgment
• Excellent organizational and multi-tasking skills.
• Ability to work effectively, cooperatively, and professionally with a diverse group of faculty and staff, and aid in the training and education of existing and new staff.
• Accurate and detail-oriented, along with the ability to oversee multiple tasks and priorities simultaneously with numerous interruptions.
• Must be able to work under pressure in a fast-paced environment, with strong time management skills.
• Demonstrated ability to work independently with a positive attitude.

Preferred Qualifications:

• 3-5 years of credentialing and privileging experience.
• CPCS certification.
• Extensive knowledge of credentialing and privileging.
• Knowledge of Hospital or clinical department policies and procedures.