Credentialing Coordinator (29011)

Why work for Ampla Health? 29011

Ampla Health provides the individuals and communities we serve with high quality, comprehensive, community health care that is accessible to all and culturally and linguistically appropriate.

• Great Benefits including Medical, Dental, and Vision
• 4 weeks paid time off to start.
• 9 paid holidays
• 401k and profit sharing
• Full time, Monday to Friday
• Great work/home life balance

Serve as lead and primary resource for all staff, provide training and work direction to all staff, review and audit credentialing files for accuracy, monitor deadlines, identify process improvements, act as liaison between PAS Manager and staff. Individual will receive 10% increase for providing lead duties.

General Purpose
Under the supervision of the PAS Manager, the Provider Credentialing Coordinator manages the credentialing and enrollment process for providers, clinics, and pharmacies. This role ensures accurate and timely submission of applications, renewals, and documentation required for participation with insurance plans, third-party organizations, and special programs.

Key Responsibilities

• Process and maintain credentialing for providers, clinics, and pharmacies
• Coordinate and submit applications, renewals, and re-validations with insurance organizations and third-party entities
• Maintain provider files including licenses, identification numbers, and credentialing documentation
• Obtain and manage provider information such as NPI and CAQH profiles
• Track credentialing status, deadlines, and expirations using spreadsheets and internal systems
• Communicate with insurance companies and outside organizations to resolve credentialing issues
• Update and maintain provider rosters and credentialing records
• Assist the PAS Manager with credentialing projects and administrative support

Qualifications

• High school diploma required; some college preferred
• Minimum four (4) years of clerical or administrative experience
• Credentialing experience with providers, clinics, or pharmacies preferred
• Proficiency in Microsoft Excel and general office systems
• Strong organizational skills and ability to manage deadlines

Skills & Attributes

• Detail-oriented with strong problem-solving abilities
• Professional communication and interpersonal skills
• Ability to work independently and manage multiple credentialing processes

GENERAL PURPOSE:

Under the supervision of the PAS Manager, the Provider Credentialing Coordinator processes all applications forms, agreements and correspondence associated with all preferred provider organizations, independent provider organizations, special programs, other third party provider and group organizations, pharmacy credentialing for all entities with whom Ampla Health has established or would have contractual relationships with.

MAIN RESPONSIBILITIES & DUTIES:

1. Processes and maintains up to date individual providers, clinics and pharmacy credentialing.

2. Coordinates and secures the necessary information and completes forms to satisfy the individual provider criteria, clinic and pharmacy credentialing requirements for both initial application as well as annual renewals and re-credentialing/re-validations of clinics and pharmacies.

3. Coordinates contracts, and coverage changes which have been approved by the Chief Financial Officer

4. Maintains current essential files for providers, clinics and pharmacies ensuring that addresses, licenses, ID numbers, etc., are kept up to date, and readily available for credentialing purposes

5. Obtaining and establishing provider’s information

6. Obtains National Provider Identifier (NPI), if necessary, via National Plan and Provider Enumeration System (NPPES) online site

7. Establishes and/or obtain access to provider’s Council for Affordable Quality Healthcare (CAQH) Universal Credentialing Data Sources file

8. Reviews initial information and supply PAS Manager with provider file data

9. Updates and maintains the provider roster as needed

10. Reviews status of any credentialing in place at time of hire, going directly to previous employer, if necessary

11. Sends and submits letter/application to organizations

12. Sends out letters of provider credentialing transfer to active organizations

13. Sends out letters of credentialing request for those organizations aligned with Ampla Health

14. Completes applications when received and submit back to organization within the specified timeframe.

15. Sends out terminations letters to all organizations to sever Ampla Health from established credentialing relationships

16. Assists the PAS Manager in determination of the feasibility of the various proposed fees for service

17. Attends educational workshops, webinars, review professional publications, and network to maintain the provider roster, clinic enrollment, pharmacy enrollment and re-validations as needed for the various programs Ampla participates in.

18. Assists the PAS Manager with special projects as required

QUALITIES & CHARACTERISTICS:

1. Maintains a professional relationship and positive attitude with co-workers, the public, patients and all Ampla Health’s employee, Board of Directors, vendors and the many insurance companies and their representatives in order to complete the credentialing process timely and accurately.
2. Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through his/her actions
3. Strives to learn more and is receptive to learning different ways of doing things
4. Displays enthusiasm toward the work and the mission of Ampla Health

PROFESSIONAL KNOWLEDGE, SKILLS & ABLITIES:

1. Graduation from high school and two (2) years college or equivalent
2. At least four (4) years performing clerical and/or bookkeeping duties
3. Knowledge of individual provider, clinic and pharmacy credentialing preferred.
4. Working knowledge of Microsoft Excel, creating and updating spreadsheets.  Track expiration dates, maintain accurate information and meet critical deadlines for submitting information to insurance companies.
5. Must have some business knowledge of office procedure and supervisory skills
6. Ability to use general office equipment such as computer, typewriter, copy machine, telephone, etc.
7. Demonstrate clear knowledge of Ampla Health’s clinic structure, standards, procedures and protocols

COMMUNICATIONS SKILLS:

1. Must be able to read and interpret complicated guidelines and processes based on what Ampla entity is being credentialed.  Requirements are different for each type (provider, clinic, pharmacy).
2. Be able to work independently and document requirements for each type of credentialing.
3. Contact outside entities you are credentialing with and work to resolve complex issues as needed.
4. Must have neat and legible handwriting
5. Must be able to interact with patients courteously and calmly
6. Ability to communicate well with the public

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

Works well with patients, co-worker, vendors, insurance company representatives in a generally comfortable environment. Employee must possess the following physical requirements:

1. Must be able to hear and communicate with clients, insurances and staff on telephone and those who are served “in person”, and speak clearly in order to communicate information to all involved.
2. Able to move up to 50 lbs. (small equipment, supplies, etc.)
3. Must have vision which is adequate to read memo’s, computer screen, registration forms and other clinic documents
4. May be exposed to contagious/infectious diseases
5. Able to reach above shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouch, reach, kneel, twist/turn
6. May be exposed to contagious/infectious diseases