OVERVIEW OF POSITION:

The Credentialing Specialist will be responsible for all aspects of the credentialing, recredentialing and privileging processes for all medical providers who provide patient care, clinics, and facilities. In this role, the Credentialing Specialist will be responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities and maintain up-to-date data for each provider in credentialing databases and online systems; ensuring timely renewal of licenses and certifications.

ESSENTIAL FUNCTIONS:

• Processing initial credentialing and re-credentialing applications
• Screening practitioners’ applications and supporting documentation to ascertain their eligibility
• Identifying discrepancies in information and conducting follow-ups
• Maintenance of internal and external databases (CAQH, PECOS, NPPES)
• Assisting patients with credentialing inquiries
• Responding to health plan providers inquiries
• Responsible for follow-up after submission to ensure that health plans have appropriately processed the request and that provider information shows correctly on the health plans website
• Audits Health Plan Directory
• CAQH creation and maintenance experience
• Medicare & Medicaid enrollment and revalidation
• Perform provider roster reconciliation
• Initial and reappointment of hospital privileges.
• Internal and external support for health plan issue resolution

REQUIREMENTS:

• High school diploma/GED required
• 1 years of experience working for a health maintenance organization, health plan, provider office and/or in another health insurance-related setting
• Experience with Managed Care Organizations (MCO's) and Centers for Medicare & Medicaid Services (CMS) credentialing and registration requirements
• Experience with provider and practitioner credentialing process, timeframes and appeal options; health plan design, contracting, plan policies and procedures; MCO reporting and recordkeeping requirements.
• Ability to build professional cross functional working relationships among all levels of the organization.
• Ability to make valid judgments, formulate recommendations or action plans, and evaluate the effects of decisions and actions.

KNOWLEDGE, SKILLS, ABILITIES:

• Intermediate computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes
• Team player that develops strong collaborative working relationships with internal partners and can effectively engage and ability to build consensus among cross-functional teams

• Comprehensive benefits package, including Health, Vision, Dental, and Life insurances
  • FSA and Life Assistance Program (EAP)
  • 401(k) Retirement Plan
  • Health Advocacy, Travel Assistance, and My Secure Advantage
• PTO Accrual and Holidays

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