·Credentialing and Privileging
Responsible for articulating and exercising expertise in presenting each credentialing file to the Credentials Committee on a monthly basis. Perform a detailed analysis of a medical staff applicant's profile by adhering to established standards as mandated by CMS, The Joint Commission, NCQA and URAC as they pertain to the primary source verification process. Critical thinking and analysis of this information is crucial to initially determine the credibility of medical staff professionals. Perform and review criminal background checks and NPDB on medical staff applicants and follow up if anything is found. Verify employment history, education, licensure, malpractice claims, and Medicare/Medicaid sanctions with primary source documentation. Complete reappointments for divisions on a biannual basis. Communicate with medical staff applicants to ensure accuracy and thoroughness of applications. Perform processes in accordance with established contracts, federal and state law, regulatory and accrediting agencies, and CHMC policies to ensure that valid and timely information is provided for practitioner credentialing decisions. Coordinate and process temporary privilege requests in accordance with policy.
Enter payors in the provider's computer profile. Send enrollment applications to commercial and state payors. Create an enrollment application and send to out-of-area payors within 5 business days after receiving claim. Send applications to appropriate hospital divisions. Contact representatives from commercial payors, state Medicare/Medicaid, and hospital divisions via e-mail or telephone to check enrollment status of providers. Update in computer database the expected date the application is to be returned by state payors and by hospital divisions. Identify and resolve enrollment issues with third party payors as well as maintain providers' eligibility with contracted payors.
·Data Collection & Reports
Responsible for the accuracy and integrity of the credentialing, privileging and enrollment database as well as generating ad hoc reports as needed for members of the medical staff, hospital administration and the Board of Trustees. Respond to e-mails and phone calls within 48 hours. Update electronic spreadsheets on a monthly basis. Ensure that applicant's information is recommended from the Credentialing Committee to the Medical Executive Committee. Ensure that applicant's information is recommended from the Medical Executive Committee to the Board of Trustees.
Respect patient/medical staff rights for informed consent and the handling of confidential information as defined by Cincinnati Children's mission and applicable laws and regulation. Review timeliness, accuracy, availability and security of information. Participate in improving organizational performance through recommending areas or approaches for improvement activities, performing new procedures, collecting data and providing input to department discussions. Understands, adheres to and models Cares Standards as defined organizationally and specifically within the department.
Recognizing when sufficient information has been obtained to make a decision; evaluating available alternatives and using sound thought processes and relevant experience to make the optimal choice in a timely manner; making difficult decisions even in highly ambiguous situations
Working cooperatively with others to achieve group goals; proactively adjusting one's style and efforts to complement those of others on the team; being pleasant, agreeable, and easy to work with; valuing group success as much or more than individual success
·Interpersonal Skills - Adv
Strong interpersonal skills. Effectively communicate at all levels of the organization.
Proficiency in basic computer applications such as Microsoft Office (PowerPoint, Word, Excel), e-mail, and internet
Setting and accomplishing challenging goals; taking satisfaction and pride in producing high quality work and excelling in one's efforts
Taking responsibility for one's actions and work; accepting the consequences of one's behavior; admitting mistakes
Meticulously keeping track of details without becoming overwhelmed by them; being exacting, precise, and accurate; spotting minor imperfections or errors and taking action to correct them
Being open to change and considerable variety in work activities; effortlessly adjusting to new or changing situations and unexpected events; altering one's approach to tasks and projects with minimal loss of efficiency
Challenging the status quo and seizing opportunities to enhance work processes and outcomes; voluntarily seeking new or extra responsibilities and challenges; going beyond what is expected; proactively delving into work without hesitation
Ability to effectively manage multiple tasks simultaneously
Consistently honoring promises, fulfilling obligations, and meeting deadlines; always being at work when expected; dependably arriving to and leaving work and meetings at the scheduled times
Remaining composed and calm when faced with setbacks, disappointments, rejection, crises, stress or pressure; readily putting aside concerns to get the job done; taking a problem solving rather than an emotional approach when faced with a difficult situation; being even-tempered and non-defensive
Working hard to conscientiously and thoroughly complete work; pushing oneself to successfully continue working on a task in the face of obstacles or setbacks; working continuously and intensely over long periods of time
Using inductive and deductive reasoning to formulate general rules or principles and apply them to work; identifying flaws in logical reasoning; understanding complex conceptual relationships; accurately detecting underlying themes or patterns in data
Ability to independently work through details of a problem to reach a positive solution
Excellent verbal, written and/or interpersonal communication skills