Credentialing Administrator I

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

Job Location (Full Address):

135 Corporate Woods, Ste 380, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:

Regular

Time Type:

Full time

Scheduled Weekly Hours:

40

Department:

910397 URMC Medical Staff Services

Work Shift:

UR - Day (United States of America)

Range:

UR URG 109 H

Compensation Range:

$27.16 - $38.03

Responsibilities:

Coordinates departmental activities to ensure quality in conducting, maintaining, and communicating practitioner credentialing, privileging, and primary source verifications. Serves as a resource to and collaborates with management and others to advance the quality of practitioners and patient safety of the facility.

ESSENTIAL FUNCTIONS

Coordinates Activities for Ensuring Compliance with Accreditation Standards and Regulatory Requirements:

• Develops and/or updates applicable governing documents (bylaws, credentialing policies and procedures, privileging polices, etc.) that support and direct organizational practices and ensure compliance with all regulatory agencies that govern healthcare.
• Assist management with the NCQA Accreditation application & survey process which includes completing the online application, coordinating the payments and scheduling of the survey, and participating in the survey process in coordination with MSS Management & Medical Staff leadership.
• Completes monthly ongoing monitoring for all active providers.
• Completes quarterly quality improvement metrics for NCQA survey submission.
• Represent MSS and the CVO for regulatory audit/surveys by the JC, NCQA, DOH, CMS, Delegated Commercial Payers and any other regulatory agencies as needed.
• Serve as the MSS Representative on the Joint Commission Steering Committee.
• Provides education to staff pertaining to medical staff bylaw, policies and procedures.
• Collaborates with various national and state leaders and associations and attend educational seminars and/or conferences to remain current with best practice, evolving standards, and technology and service options available to the industry at large.

Clinical Privileging and Delineation of Privileges

• Assists with the clinical privileging program and the development and maintenance of specialty-specific, criteria-based delineations of privileges.
• Collaborates with Department Chiefs, Division Heads, clinical leaders, Quality Management, and other subject matter experts to ensure privilege criteria remain current, evidence-based, reflect contemporary clinical practice, and comply with accreditation standards, regulatory requirements, and organizational policies.
• Assists in development and review of privilege criteria for new procedures, technologies, and services introduced to the organization. Research relevant specialty society recommendations, regulatory guidance, professional standards, industry resources, and practices at comparable healthcare organizations.
• Provides administrative oversight and compliance monitoring of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) documentation in accordance with applicable regulatory requirements, Medical Staff Bylaws, and organizational policies.

Data Management and Process Improvement Functions: 

• Develops and implements tools and policies to support knowledge management, record-keeping, and internal and external communication.
• Responsible for maintaining data and ensure security is appropriate and limited to the client/hospital affiliate and the staff.
• Develop, coordinate and monitor the quality initiative activities including and not limited to tracking staff performance of file processing accuracy and completion rates.
• Review performance measures and goals with staff regularly.  Develop performance improvement plans as applicable for staff not meeting goals.
• Responsible for ongoing review and assessment of the departmental functions and services to identify areas in need of improvement and implement changes as needed.
• Maintain account data to be able to provide accurate reporting on active and historical medical and allied health professional staff.
• In collaboration with the Credentialing & Accreditation Manager and Payer Enrollment Manager, assists with the functions related to URMFG’s Delegated Credentialing/ Commercial Payer Enrollment Contracts with over 25 contracted commercial payers.
• Assists MSS Management with reviewing new and existing Commercial Payers delegated credentialing contracts for appropriateness.

Department, Committees and Board Approval Process:

• Prepares the applicant credentials files for presentation to the CPRC process. This includes the collection of documents and completed files and creating combined PDF files for management and committee members to review and assists with agenda preparation as needed.
• Electronically routes the credentials files to the department chief/chair or designee for review and recommendation for membership and privileges for Strong Memorial Hospital and Highland Hospital.
• Coordinates the weekly expedited credentials committee and board approval process for credentials files being recommended by the departments for Strong Memorial Hospital and Highland Hospital.
• Coordinates emergency privilege requests for hospital privileges as needed for all UR affiliates.
• Monitors and updates staff status of appointments and privileges (Links the electronic Delineation of Privileges to the practitioner files).
• Upon committees and board approval, prepares board letters and special mailings as applicable and communicates the outcome to practitioners, and department’s representatives as applicable.

Performance Management and Recruitment:

• Recruits and supervises qualified staff to accomplish departmental operations and functions.
• Responsible for thoroughly assessing performance and processes and identifying areas of opportunity for improvement of processes and utilization of resources.
• Develops performance improvement plans as applicable for staff not meeting goals.
• Develops and implements tools and policies to support knowledge management, record keeping, and internal and external communication
• Collaborates with and assist the management team with the overall management and supervision of all Medical Staff Services Department staff which includes team building and the development and implementation of retention strategies.

Liaison and Leadership Support:

• In collaboration with the Credentialing & Accreditation Manager and Payer Enrollment Manager, assists with the functions related to URMFG’s Delegated Credentialing/ Commercial Payer Enrollment Contracts with over 25 contracted commercial payers.
• Assists MSS Management with reviewing new and existing Commercial Payers delegated credentialing contracts for appropriateness.
• Prepares practitioners credentials files for presentation to affiliate and non-affiliate CVO clients and coordinates the electronic routing through the credentialing software or other secure electronic process.
• Coordinates the proxy credentialing process associated with telehealth activities and assists management with tracking.
• Assists management with review and assessment of departmental functions and services to identify areas in need of review or improvement and implement changes as needed.
• Engages in ongoing collaboration and coordination of activities with the Credentialing Managers and other Coordinators.
• Represents the Medical Staff Office and CVO for regulatory audit/surveys by the JC, NCQA, DOH, CMS or any other regulatory agency as needed.
• Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
• Serves as a resource for staff pertaining to medical staff bylaw, policies and procedures.
• Represents the Medical Staff Services Department for various initiatives and/or committee meetings as needed.
• Serves as the primary back up to all credentialing staff.
• Serves as a Team Peer Interviewer as needed.

MINIMUM EDUCATION & EXPERIENCE

• Associate's degree in business or healthcare related field and 3 years of experience in Medical Staff credentialing and/or payer enrollment functions required
• Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

• Fluent English language skills (oral and written) required
• Proficiency in MS Office (e.g. Word, Excel, and PowerPoint), email, and internet required
• Knowledge of and experience with Joint Commission, CMS, and NCQA Regulations related to medical staff services and Commercial Payers Credentialing preferred
• Exceptional interpersonal and communication skills preferred
• Ability to develop and maintain relationships with a variety of key stakeholders across the organization preferred
• Knowledge of and experience with database applications preferred
• Experience with criteria based clinical privileging process preferred.
• Demonstrated strong familiarity with clinical environments preferred.

LICENSES AND CERTIFICATIONS

• Certified Medical Professional Services Management (CPMSM) upon hire preferred
• Certified Provider Credentialing Specialist (CPCS) upon hire preferred

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.