The Credentialing & Patient Access Specialist is responsible for successfully completing initial and subsequent credentialing of primary care providers (PCPs) with health insurers and Independent Physician Associations (IPAs) as required, responding to document and information requests from those insurers / IPAs, and for supporting patient access and growth teams to ensure patients are appropriately assigned to under the company's managed care agreements.

Duties / Responsibilities :

• Develop and maintain a credentialing checklist and process for new and existing PCPs
• Maintain individual provider files to include up to date information needed to complete the required governmental Medicare Advantage insurer and IPA credentialing requirements
• Maintain internal provider grid to ensure all information is accurate and logins are available
• Update each provider's CAQH database file according on a regular schedule to ensure that current documents are available for insurers and other managed care organizations
• Apply for and renew annually all provider licenses; necessary professional certifications, DEA registration and similar paperwork
• Maintain accurate provider profiles on CAQH, PECOS, NPPES and CMS databases
• Complete revalidation and re-credentialing requests issued by Medicare, Medicaid programs, Medicare Advantage insurers and IPAs
• Regularly review insurers' public-facing provider directories to ensure that PCPs are correctly listed in each market where we operate
• Collaborate with talent acquisition leaders to monitor the recruitment status of PCP candidates, ensure the timely collection and submission of credentialing information and documents, while minimizing the administrative burden on our clinical team
• Support managed care contracting team to compile and submit provider credentialing information in the course of establishing new insurer or IPA partnerships
• Other responsibilities and duties as assigned.

Required Skills and Abilities :

• Demonstrated knowledge of insurer / managed care credentialing processes, tools and documentation
• Experience working in a managed care environment, and with the patient access and assignment mechanics common under HMO plans
• Service-oriented mindset, with the drive to proactively identify potential administrative challenges and resolve these independently
• Experience developing and implementing administrative processes in a growing healthcare organization
• Strong verbal and written communication skills
• Ambitious, detail-oriented, self-starter, persistent, goal-oriented
• Strong computer skills, ideally with experience using G Suite, Slack, CAQH and other credentialing tools (or the aptitude to learn quickly)
• Comfortable and disciplined to work in a remote environment
• Desire to quickly learn through on-the-job experience
• Thrives in a goal-driven, fast-paced work environment
• Excellent computer skills
• Ability to obtain, synthesize and analyze data and recommend solutions.
• Ability to work on multiple projects concurrently.
• Possesses a learning and growth mindset; creative thinker.

Education and Experience

• BS or BA preferred
• 2-4 years of experience in healthcare;
• 2 years in provider credentialing or billing
• Project management experience is a plus
• Experience working with Electronic Health Records
• Certified Provider Credentialing Specialist - CPCS preferred.
• Non ClinicalCPMSM - Certified Professional Medical Services Management preferred.

Physical Requirements :

• Ability to remain seated in a stationary position for prolonged periods
• No heavy lifting is expected, though occasional exertion of about 25 lbs. of force (e.g., picking up and computer / laptops) may be required
• Good manual dexterity is required to use common office equipment (e.g., computers, laptops, and mobile devices)

Last updated : 2024-02-24