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Credentialing Specialist

 

Credentialing Specialist - Orlando Health Emergency Room and Medical Pavilion Osceola

Orlando Health is currently seeking a Credentialing Specialist, HealthPlan who will be responsible for the activities to complete the review of all credentialing and re-credentialing applications submitted to Healthchoice.

Education/Training

Associates degree in a healthcare related field. Four (4) years of directly related work experience may substitute for the Associates degree (in addition to the requirements listed in the Experience section). Knowledge of Microsoft Office applications software including Access database.

Licensure/Certification

None

Experience

Three (3) years of managed care provider credentialing experience required.

Essential Functions

Interacts and communicates with physicians and various Orlando Health departments to obtain information necessary to complete all credentialing and re-credentialing activities.

Interprets all NCQA (National Committee of Quality Assurance) guidelines, URAC (Utilization Review Accreditation Committee), as well as Federal and State health care program guidelines and then develops, revises and implements the appropriate credentialing and re-credentialing processes to adhere to these national guidelines.

Oversees the coordination of HealthChoice delegated credentialing and re-credentialing for HealthChoice physicians, Orlando Health employed physicians, and contracted physicians as well as allied health and mid-level practitioners ensuring compliance with regulatory, accreditation and various managed care plan policies and protocols, standards and requirements

Leads, schedules, coordinates and oversees the successful completion of audits from both state regulatory agencies and all managed care plans through the Orlando Health delegated arrangements

Develops and fosters relationships with managed care plans, state agencies and physician partners to facilitate timely credentialing and re-credentialing

Acts as a troubleshooter in resolving departmental issues related to credentialing and develops performance improvement plans as needed

Identifies trends in regards to medical malpractice regulations and guidelines and makes recommendations to the Medical Director and Credentials Committee based on those guidelines and standards

Other Related Functions

Maintains confidentiality of data and information.

Assumes responsibility for professional growth and development.

Participation in other activities as directed by the Manager, Healthchoice.


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