Description

Position Summary

The Credentialing Specialist is responsible for organizing, coordinating, monitoring and maintaining the primary source verification for providers credentialing and recredentialing. Ensures compliance with the appropriate accrediting and regulatory agencies, internal policies and procedures as well as the health plans. Responsible for the integrity of the credentialing database system and related applications. Works under the supervision of the Vice President of Network Operations.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

Primary

1. Leads, coordinates, and monitors the review and analysis of practitioner applications and

accompanying documents, ensuring applicant eligibility.

2. Conducts thorough background investigation, research, primary source and secondary source verification of all components of the application file.

3. Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.

4. Prepares credentials file for completion and presentation to the Credentialing Committee, ensuring file completion within time periods specified.

5. Responds to inquiries from health insurance companies, interfaces with internal and external customers on day-to-day credentialing and recredentialing issues as they arise.

6. Assists with managed care delegated credentialing audits; conducts internal file audits.

7. Utilizes Medisis for credentialing, optimizing efficiency, and performs query, report and

document generation.

8. Monitors the initial, reappointment and expirable's process for all physicians and other allied health professionals, ensuring compliance with regulatory bodies (JCAHO, NCQA, URAC, AAAHC, CMS, federal and state), as well as policies and procedures, and delegated contracts.

9. Assist in mentoring and training new hire Credentialing Specialists for success.

10. Assist in preparing and submitting Credentialing Department projects, reports or assignments as needed to meet department initiatives, Health Plan reporting, and/or objectives.

11. Notifies Credentialing Manager of any re-occurring credentialing issues or opportunities for process improvement.

12. Able to work independently with minimal supervision. Ability to work productively and well under pressure.

13. Ability to maintain confidentiality of privileged information gained.

Minimum Qualifications (Knowledge, Skills, and Abilities)

Education

Must have high school diploma or general education degree (GED).

Experience & Job Knowledge

High School or six months to one year related experience and/or training; or equivalent education.

Skills

Ability to read, assess, and process credentialing and recredentialing requests timely with attention to detail. Excellent communication skills including good grammar, voice and diction. Ability to navigate software systems and proficient in MS Office and Excel with basic computer and keyboarding skills. Excellent customer service skills. Proactive in conflict resolution.

Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.

Physical

Requires corrected vision and normal hearing range, requires sitting for extended periods and extended periods of computer use; may also require standing, walking, bending, kneeling, and crouching; occasionally lifts and carries items in excess of 5 to 10 lbs. but not more than 20 lbs. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Core Competencies

Commitment and Accountability: must produce promised results in a timely manner. Must coordinate and manage multiple credentialing requests and provider calls. Professionalism: must work professionally with all levels of internal and external customers to other departments, associates and clients. Communication: must communicate verbally and in written form in a professional, logical, and persuasive manner with external and internal clients. Motivation and Initiative: must have the initiative and ability to work independently and in an unsupervised environment. Judgment: must analyze problems, develop courses of action, and implement decisions that are consistent with department policies, procedures and/or objectives. Planning: must effectively organize, prioritize, and carry out numerous tasks simultaneously. Must adjust to changes quickly and in a positive manner.

Working Conditions

Work is performed indoors in a controlled environment. Occasional reports and meetings require attendance after regular business hours.