Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Responsible for verification of practitioner credentials at all NGHS facilities (participating programs) in accordance with regulatory standards and the System Operating Manual guidelines. Ensures integrity of provider database. Works cooperatively/collaboratively with practitioners, their office staff and participating programs to facilitate the verification process. Functions as an intricate part of the System Medical Staff and Verification Services team. Performs projects as assigned.
Minimum Job Qualifications
Licensure or other certifications:
Educational Requirements: High School Diploma or GED.
Preferred Job Qualifications
Preferred Licensure or other certifications: CPCS or CPMSM certification.
Preferred Educational Requirements: Associates or Bachelors Degree preferred or equivalent experience.
Preferred Experience: Two (2) to five (5) years credentialing experience in a managed care organization, hospital or medical practice.
Job Specific and Unique Knowledge, Skills and Abilities
Knowledge of Medical staff organization, DNV, CMS, NCQA and state of Georgia regulatory standards preferred
Computer skills required
Excellent written and verbal skills; attention to detail; excellent customer relations skills.
Must be flexible, ability to adjust to changing priorities on a daily basis. Willing to work flexible hours to meet the needs of the department.
Must be able to exercise sound judgment and maintain strict confidentiality
Essential Tasks and Responsibilities
Initiates requests for Pre-Application if practitioner meets Board criteria.Reviews completed pre-application and assures compliance with NGMC Board criteria and submits to NGMC Board subcommittee for approval with any noted non-compliance with Board criteria.If approved, initiates initial application and privileges to provider. If criteria not met, initiates letter to applicant denying request for application specifying the criteria not met.
Initiates requests for initial application to include: Applications, supporting forms and appropriate clinical privilege requests to applicants at any NGHS participating program upon request by participating program.
Initiates reappointment applications according to the guidelines of the Operating Manual. To include Additional privilege request or status changes.
Maintains all aspects of the application process for all NGHS facilities to include the distribution, timely receipt and review of applications for completeness and accuracy.Reviews application for compliance with the established eligibility criteria.Coordinates the return of incomplete applications as deemed necessary.Reviews applications following up to obtain additional information from applicant as needed per the Operating Manual.
Demonstrates the ability to organize and maintain a coordinated process for the collection and verification of credentialing data.
Conducts primary source verification of credentials according to regulatory standards and the Operating Manual
Assures required case logs, education and documentation in applicant file to support clinical privileges requested.Follow-up with applicant on any required documentation.Marks applicant with "red flag" if required documentation is not provided.
Responsible for examining each verified item for potentially adverse information.Potentially adverse information is defined as any information that is or has the potential of having adverse bearing on the evaluation of the practitioner.This adverse information is identified by a "red flag" in the provider database system.
Communicates regularly with all applicants and respective participating programs regarding status of application.Ensures verification information is updated regularly to allow participating programs and applicants to review progress of individual applications.
Communicates timely to participating program on any potential "red flags" identified through the verification process with applicant information.Collaborates with participating program to assist in obtaining additional information regarding "red flag" if requested.
Consistently meets deadlines of application and reapplication processes as outlined in Operating Manual processes.Maintains accurate records of request for application and all aspects of application and verification process in order to assure proper documentation of timelines.
Updates and maintains provider database system ensuring integrity of data.
Maintains current enrollment of practitioners in the National Practitioner Databank. Adds, Removes, and renews for each facility.
Ensures that current verification of all expirables i.e. Georgia license, DEA, insurance, board certification and other required certifications are maintained in the credentialing system.
Processes requests for additional privileges and staff status changes in compliance with standard work, a part from Reappointment.
Notifies Systems Analyst of any related provider database concerns or issues for resolution.
Assists, as requested, with preparation for external credentialing audits and regulatory examinations providing required information as needed.
Participates and organizes, as requested, meetings of the System Oversight Committee, providing reports as requested.
Maintains current knowledge of certification standards necessary to perform the duties herein.Ensure compliance with DNV, CMS, medical staff bylaws, and state/federal requirements.Actively participates in all accreditation processes and regulatory site visits.
Maintains compliance and promotes quality customer service.Reports controversial issues to the Director.Collaborates with MSVS staff to resolve practitioner satisfaction issues ensuring concerns are investigated, reported, and appropriate action is taken to resolve issues.
Contributes to the success of the Department, Hospital and System by actively participating in setting and accomplishing goals and objectives.
Participates in Quest for Excellence activities by contributing suggestions, experience and expertise to promote efficiency and excellent outcomes.
Develops, reviews and updates standard work, department policies and procedures pertaining to individual duties and responsibilities to ensure department compliance with all state, regulatory and hospital requirements.
Contributes routinely to his/her own professional growth and that of the department and professional colleagues.
Participates in departmental daily huddles.
Uses Error Prevention Tools on an ongoing basis.
Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
Weight Carried: Up to 20 lbs, Occasionally 0-30% of time
Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.
Northeast Georgia Health System (NGHS) is a not-for-profit community health system dedicated to improving the health and quality of life of the people of Northeast Georgia. Through the services of a medical staff of more than 600 physicians, the residents of northeast Georgia enjoy access to the state's finest and most comprehensive medical services. It is our mission to improve the health of our community in all we do.