Kaiser Permanente Credential & Privileging Specialist - MHS in Wailuku, Hawaii
The Credentialing and Privileging Specialist will coordinate, monitor, and prepare documentation for all practitioners both inpatient and/or outpatient services in all applicable health care settings. The production of a file, approval and its audit will focus on correct assignment of required documents to include but not limited to those that complete a practitioner profile. The clinical performance data as defined by regulatory bodies is prepared, evaluated, distributed to applicable parties as a part of ongoing oversight as defined by accrediting bodies. The end product and clinician documentation is to ensure that Kaiser Permanente is compliant with all regulatory guidelines and internal controls. The preapproval audit of documents will encompass internal practitioners, contracted practitioners, internal facilities and contracted facilities. Analyzes and audits results, identifies patterns, trends or variations in file and documentation practices and make recommendations for improvement. When necessary, this position will initiate corrective action plan to ensure resolution of problem areas identified during auditing and monitoring activity. This position will serve as a liaison with respective clinical chiefs, credentials committee, medical executive committee, and other regional departments as appropriate.
Ensure that all practitioner documents, acquired are based on and meet requirements of current federal regulatory requirements e.g. the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, National Commission on Quality Accreditation and current program documentation guidelines, as well as, ensuring compliance with departmental/internal policies and other applicable laws and regulations.
Prepare written audit report for all noted file deficiencies and make recommendations to Clinical Chief, Credentials committee and Medical executives and others as appropriated/requested (i.e. training, oversight, monitoring, process flows, etc.).
Develop and deliver education and training to new clinical leaders and or departments who have credentialed practitioners or organizational providers related to results of document reviews, and findings from Regulatory bodies and other audits.
Compares file content profile, privileges and ongoing evaluation periods with regional and national norms and regulatory/accreditation bodies. Reviews Clinical Chief, committee or program queries to include denials.
Receives, investigates reports of file discrepancies. Communicates results to Credentials supervisor and or director. Ensures appropriate dissemination and communication of all regulation, policy, and guideline changes to affected personnel.
Minimum two (2) years credentialing experience in managed care or hospital setting including handling complex files/requests requiring independent judgment.
Associate's degree in health care or technical field; or two (2) years experience in a directly related field.
License, Certification, Registration
Knowledge of and experience with effective office procedures, including filing systems, electronic record systems, routing procedures, and business organization and practice.
Knowledge of and experience with medical terminology and relevant state laws and accreditation regulations.
Demonstrated knowledge of and skill in written communication, oral communication, interpersonal relations, adaptability (flexible work situations), influence (with physicians and senior executives), problem solving, project management, quality management, results orientation (meeting deadlines) and teamwork.
Demonstrated knowledge of and skill in word processing, Spreadsheet and database (credentialing/tracking system) PC applications.
Experience working with physicians and/or senior executives.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) by the National Association Medical Staff Services (NAMSS).
Bachelor's degree in health care or technical field.
TITLE: Credential & Privileging Specialist - MHS
LOCATION: Wailuku, Hawaii
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.