Credentialing Audit Specialist presso Ephraim McDowell Regional Medical Center, Inc.

Job Summary

The Medical Staff Services Insurance Audit/Policy Coordinator is a critical role responsible for ensuring compliance with state and federal regulations, accreditation standards, and insurance requirements. This individual will oversee cooperative care insurance audits, credentialing processes, and ensure providers and the facility meet industry standards and regulatory requirements. The ideal candidate will have expertise in Kentucky state licensure regulations, The Joint Commission standards, and the National Committee for Quality Assurance (NCQA) guidelines. This position requires exceptional organizational skills, attention to detail, proactive management of issues, and independent work management skills in a highly confidential and sensitive environment. This position is crucial for maintaining the integrity of the cooperative care program and ensuring adherence to insurance and regulatory requirements. The successful candidate will demonstrate a proactive approach to auditing, policy development, and credentialing management while exhibiting the values of Friendliness, Innovation, Respect, Service, and Trust.

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:

1. Ensure the facility complies with Kentucky state licensure regulations, The Joint Commission standards, and NCQA guidelines.
2. Research new regulatory requirements for both the facility and providers.
3. Develop and maintain Bylaws, Policies, and Procedures that align with current laws and accreditation standards.
4. Monitor information collection and follow up to obtain missing documents.
5. Maintain personal adherence to professional confidentiality standards established within the Department and in accordance with legal, ethical, and organizational policies.
6. Assure data security and confidentiality of all files by securing appropriate file areas, cabinets, drawers, and computer terminals.
7. Manage cooperative care insurance audits by reviewing files, ensuring accuracy, and addressing discrepancies.
8. Act as the primary liaison with insurance auditors to facilitate smooth communication and resolution of issues.
9. Analyze trends from audits to recommend process improvements.
10. Implement action plans for corrections.
11. Oversee credentialing, re-credentialing, and privileging processes for medical providers.
12. Review provider qualifications and performance to maintain high-quality care delivery.
13. Present findings from cooperative care file reviews at board meetings with physician advisor.
14. Maintain an integrated database for all cooperative care providers.
15. Process new applications, student/resident/fellow requests for rotations.
16. Enter new providers into the Meditech Provider Dictionary.
17. Ensure providers are credentialed, re-credentialed, and participating with health plans, hospitals, and patient care facilities.
18. Maintain up-to-date data for each provider in credentialing databases and online systems and ensure the timely renewal of licenses and certifications.
19. Closely monitor information collection and follow up to obtain missing documents.
20. Ensure confidential credentials files are orderly and current, and follow up with providers to obtain renewal information.
21. Maintain a database of physicians and allied health, including demographic information, privileges granted, department and committee appointments/attendance, continuing medical education activities, credentialing, and other related information.
22. Processes requests for applications and maintains records of applications sent.
23. Maintain thorough documentation of audits, policies, and compliance efforts.
24. Prepare detailed reports for leadership on audit findings, compliance gaps, and corrective actions.
25. Ensure confidential credentials files are orderly and current.
26. Able to assist with reports as requested through the designated medical staff credentialing software.
27. Maintains resignation logs of cooperative care providers and completes the process of physician resignations within the medical staff office.
28. Coordinates yearly credentialing audits with contracted health insurance entities to come and review credentialing files, policies, procedures, and minutes for the Cooperative Care Network.
29. Complete all activities involved in the preparation of reports, minutes, policies, bylaws, rules and regulations, procedures, and correspondence to facilitate department operations.
30. Answer telephone calls and direct to the correct location/department.
31. Work closely with medical staff, administration, and external partners to align policies with operational goals.
32. Act as a provider relations representative for Cooperative Care.
33. Provide education to staff regarding compliance requirements and best practices.
34. Resource for Medical Staff projects.

WORKING CONDITIONS, HAZARDS, AND PHYSICAL EFFORT:

Works in an office environment. May require extended hours. Normal hours are Monday-Friday 8.30am -5:00 pm. Minimal risk exposure to disease, infection, physical strain, exposure to blood, body fluids, and tissue. This may result in periods of increased levels of stress. High degree of a stationary position and time spent at a computer terminal. Must be able to move or position 25 lbs independently.

EQUIPMENT USED/SPECIAL SKILLS REQUIRED:

1. Strong knowledge of credentialing processes, medical staff bylaws, and insurance plans.
2. Ability to interpret complex regulations and apply them effectively.
3. Exceptional organizational and time management skills.
4. Proficiency in data analysis tools and medical staff credentialing software.
5. Excellent communication skills for interacting with auditors, board members, medical staff providers, and Associates.
6. Ability to maintain confidentiality and handle sensitive information.
7. Competence in computer skills including Google Documents Platform, data input, gap analysis, and action plan development.
8. Intermediate typing speed (e.g., 50 words per minute) with accuracy.