Credentialing Coordinator (52341)
Summary
Coordinates provider credentialing and recredentialing for a Medicare Advantage HMO, ensuring compliance with CMS, state/federal regulations, and internal policies. Verifies qualifications, maintains records, and supports onboarding while collaborating with departments to uphold operational efficiency.
WHO WE ARE:
GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.
WHO YOU ARE:
The Credentialing Coordinator is responsible for coordinating and maintaining the provider credentialing and recredentialing process to ensure compliance with CMS Medicare Advantage requirements, applicable state and federal regulations, contractual obligations and organizational policies. This role verified provider qualifications, maintains accurate credentialing records, supports timely provider onboarding and collaborates with departments and delegated entities to ensure operational efficiency and regulatory compliance.
ESSENTIAL JOB FUNCTIONS:
- Processes applications and credentialing files, checking for completeness and accuracy.
- Obtains primary source verification of competencies relating to the applicant such as relevant board certifications, health facilities affiliations, licensure, certifications, DEA, OBNDD certificates, and malpractice coverage following GlobalHealth Policy and Procedures including NCQA requirements.
- Queries and processes primary source verification and accreditation information including NPDB, OIG, SAM, Revoked Medicare Providers & Suppliers and Medicare Opt Out.
- Emails or faxes GlobalHealth Provider Data Forms or UCA applications for initial credentialing and reappointment when requested.
- Downloads provider application and all available primary source verified documents from CAQH
- Prepares credentialing files and submits practitioner and provider information to Credentialing Committee for approval in timely manner.
- Continuously maintains and updates accurate credentialing files and database for both practitioners and providers. Maintains communication with appropriate practitioners to ensure records are up-to-date and consistent.
- Assists Supervisor of Credentialing, and other leaders and Executive Credentialing Committee to ensure that proper credentialing procedures are followed.
- Notifies practitioners and providers of Credentialing Committee decisions and renewal dates and responds to request for status of credentialing.
- Manages, requests and follows up expirable as needed (license, COI, Board Certifications, etc.).
- Saves approved documentation, files to the credentialing drive, and keeps all appropriate records in provider folders.
- Maintains confidentiality of all credentialing files.
- Completes various work assignments as requested by supervisor in a timely manner.
- Maintains current desk procedures and reference materials.
- Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
- Performs other duties as assigned.