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Job Band D1

General Description of the Job Class

Under the supervision of the Manager of DUHS CVO and the Lead Credentialing Specialist, the Credentialing Specialist is responsible for all aspects of the credentialing for all medical providers who provide patient care at Duke University Health System (DUHS), Responsible for ensuring providers are credentialed in accordance with The Joint Commission, NCQA, CMS, and AAAHC Standards for health plans, hospitals, ambulatory care centers, and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of appointments and all-time limited credentials.

Duties and Responsibilities of this Level

• Processes Initial applications for DUHS, ensuring compliance with regulatory requirements.
• Obtains verification from primary sources for all regulatory requirements and monitors all applications assigned credentialing to provide updates to applicants and documents in the credentialing system in compliance with regulatory standards.
• Researches and maintains current and accurate data for all providers for the Health System within the Credentialing database.
• Verifies the legitimacy of practitioner information with the primary source of the credentials and in accordance with the accreditation regulatory standards, and state/federal laws for universities, licensing agencies, hospitals, and certification bodies.
• Maintains a complex credentialing database with up-to-date practitioner information, including medical license, drug enforcement administration (DEA) certificate professional liability insurance, board certifications, and renewal period expiration dates.
• Executes queries for the National Practitioner Data Bank (NPDB) for initial applications through NPDB Continuous Query in the Credentialing database.
• Ensures that any reports received through the queries are flagged for the Medical Staff Offices
• Presents complete Health System applications with credentialing verification materials and flags any concerns for initial applications for the Medical Staff Offices to act upon.
• Ensures data integrity within the Credentialing database for physician practice demographic information and ensures it is compliant with health plans, agencies, and other entities.
• Analyzes complex information in the credentialing application process, ensuring there are no time gaps, we are obtaining the documentation required for compliance with policies, regulatory standards, and State and Federal laws.
• Maintains confidentiality of all provider information within our credentialing database, as well as documentation gathered through the credentialing process.
• Provides credentialing and privileging verifications in accordance with regulatory standards, and state/federal laws.
• Composes, proofreads, or edits formal correspondence, memoranda, and short reports for internal and external circulations. Assembles attachments and corresponding materials. Reviews outgoing materials for completeness, dates, and signatures.
• Serves as a credentialing subject matter expert with internal and external contacts on the administration of the program and/or program policies and procedures.
• Applies office standards, policies, procedures, and authority levels when responding to questions from both internal and external customers.
• Organizes and maintains resource information and job procedures pertinent to responsibilities.
• Prepares a variety of documents, records, reports, etc. as needed to perform job responsibilities.
• Performs other duties as assigned.

Required Qualifications at this Level

Education:

Work requires analytical, communication and organizational skills generally acquired through the completion of a bachelor's degree program.

In lieu of a bachelor's degree, four years of relevant experience in Medical Staff Credentialing/Privileging (in addition to the experience requirement for the role)

Experience:

One year of experience in a Medical Staff credentialing office.

Degrees, Licensure, and/or Certification:

Certification by NAMSS (CPCS and/or CPMSM) preferred

Knowledge, Skills, and Abilities:

Maintains knowledge, as the Subject Matter Expert for compliance of delegated credentialing contracts of current health plan and agency requirements in the managed care contracts for credentialed providers.

Maintains knowledge, as the Subject Matter Expert of state/federal laws, regulatory standards for accreditation purposes, and DUHS Bylaws, policies, and procedures.  

Distinguishing Characteristics of this Level

N/A