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AdventHealth Credentialing Specialist Managed Care in Gainesville, Florida


Credentialing Specialist Managed Care AdventHealth Corporate

Location Address: 1051 Winderley Place Suite 400 Maitland, FL 32751

Top Reasons To Work At AdventHealth Corporate

  • Great benefits
  • Immediate Health Insurance Coverage
  • Career growth and advancement potential

Work Hours/Shift:

  • Full-Time, Monday – Friday

You Will Be Responsible For:

  • Coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
  • Conducts thorough background investigation, research and primary source verification of all components of the application file and ensures provider files are current and noted in detail in the system of record.
  • Achieves productivity standards as determined by management.
  • Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
  • Prepares credentials file for completion and presentation to the AHS Delegated Credentialing Committee (DCC) or other affiliated credentialing committees within AHS, including Clinically Integrated Network (CIN) committees ensuring file completion within time periods specified.
  • Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
  • Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
  • Assists with managed care delegated credentialing audits; conducts internal file audits.
  • Utilizes the MSOW/Apogee credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
  • Monitors the initial, reappointment and expirables process for all AHS employed physicians, allied health professional staff, other health professional staff, delegated and community CIN providers affiliated with AHS. Responsible for ensuring compliance with regulatory bodies (Joint Commission, NCQA, CMS, federal and state), as well as medical staff bylaws, rules and regulations, policies and procedures, and delegated contracts.
  • Performs miscellaneous job-related duties as assigned


What You Will Need:

  • High school diploma or GED
  • Minimum 5 years of healthcare experience with 1 year directly related to hospital medical staff or managed care credentialing and/or provider enrollment.
  • Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis
  • Knowledge of medical credentialing and privileging procedures and standards.
  • NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing certification and secure within 1 year in the role
  • AS Degree in healthcare, preferred
  • 4 years directly related to hospital medical staff or managed care credentialing and/or provider enrollment

Job Summary:

Responsible for coordinating, monitoring, and maintaining the credentialing and re-credentialing process. Facilitates all aspects of Adventist Health Systems (AHS) credentialing, including initial appointment, reappointment, expirables process of physicians and allied health professionals, and all other providers outlined in AHS policies, or related contracts. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications. Works under the supervision of the Centralized Verification Office (CVO) Manager.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Managed Care

Organization: AdventHealth Corporate

Schedule: Full-time

Shift: 1 - Day

Travel: No

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.