Under direction from the Credentialing Supervisor, the Credentialing Specialist is responsible for ensuring all THP affiliated physicians and other independent practitioners and allied providers are qualified to provide health care services to members in accordance with THP's policies and procedures, state laws and/or regulatory requirements (e.g. NCQA). Practitioners are recredentialed at least every three years.
* Essential functions occur simultaneously, therefore, the employee must be able to appropriately handle each essential function, prioritize them, and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment. Requires the ability to learn and apply TAHP policies consistently and seek out guidance when necessary.
1. Responsible for maintaining and processing physician and provider credentialing information for new and established health plan practitioners in accordance with THP's policies and procedures, state laws and regulatory agencies, including but not limited to:
a) Assessment of adequate and accurate information for participation in THP, including a limited knowledge of provider contract information;
b) Accurate and timely entry of initial and existing credentialing applications into the credentialing information system (Cactus);
c) Verification through various sources of necessary licenses, board certification, etc;
d) Review and report of adverse information received through National Practitioner Data Bank (NPDB), state and federal sanctions;
e) Retrieval of missing and/or expired information/documentation required for credentialing;
f) Act as resource for physician and provider questions relating to certification and/or credentialing process;
g) Identify for Credentialing Supervisor those issues of broader complexity or sensitivity that may require further action by a Medical Director or other outside source.
2. On a daily basis, prepare files that Meet Credentialing Criteria for review by the Credentialing Compliance Coordinator and/or Supervisor and presentation to daily Medical Director file review.
3. Prepare files that may not Meet Credentialing Criteria for review by the Medical Directors and/or Senior Credentialing Specialist and/or Supervisor and presentation to the Quality of Care Committee (QOCC), including report of adverse information.
4. On a daily basis, process all delegated practitioners under the terms and conditions of the entities' delegated agreement, including files credentialed through a Certified Verification Organization (CVO).
5. Participate in task forces and/or other meetings as assigned and execute other responsibilities as assigned.