Credentialing Specialist

Develop and cultivate productive relationships with providers, retail chains, strategic partners, and their staff. Elevate providers' understanding of industry standard credentialing requirements, leveraging team knowledge and resources.

Essential Functions

Establish relationships with providers to obtain required regulatory information and manage all aspects of the provider's initial and ongoing credentialing requirements. Use independent judgment to ensure that documentation complies with appropriate state regulations.

Oversee and manage assigned files in CVO partner's system. Track in-progress credentialing files, identify and collect missing documents to ensure timely completion of the credentialing process for new and existing providers, and that state regulatory standards are met.

Research, analyze, and resolve complex credentialing issues and escalations, coordinating with internal and external business partners when needed in order to meet regulatorily compliance requirements.

Use analytical and investigative skills to collect, evaluate, and compile information from regulatory reporting agencies, legal documents, and the provider to support the explanation of provider sanctions and/or malpractice claims. Compile required information for the Credentialing Committee in a clear and complete format that allows the Committee to render their decision on the provider's application.

Exercise critical thinking and analytical skills in the initial entry and maintenance of provider data, ensuring the integrity of all shared provider information.

Escalate issues to the appropriate business areas and drive solutions when applicable.

Gather and assess necessary provider information for the legal department to support the Dispute Resolution Process for providers denied at Committee or termed from the network. Compose professional and concise correspondence to providers, retail chains, and office staff.

Demonstrate a broad knowledge of the organization's strategic direction to achieve growth objectives and operational goals. Act as an internal resource for business partners.

Job Specifications

Typically has the following skills or abilities:

Bachelor's Degree in a related field; in lieu of a degree, 4 years of functional experience

Demonstrated professionalism and leadership in dealing with situations involving controversy and conflict, experience in handling and resolving escalated issues

Demonstrated advanced communication, influencing, and problem-solving skills

Experience working directly with providers and staff on credentialing policies and procedures

Regularly exercise discretion and independent judgment in the performance of job duties

Demonstrated ability to identify problems and provide creative solutions

Strong attention to detail, multi-tasking, organizational skills, and customer service skills

Proven ability to balance provider needs with corporate objectives

Ability to work independently and in a team environment

VSP Vision is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to age, gender, race, color, religion, sex, national origin, disability, or protected veteran status. We maintain a drug-free workplace and perform pre-employment substance abuse testing.

The compensation range for the role is listed below. Applicable salary ranges may differ across markets. Actual pay will be determined based on experience and other job-related factors permitted by law. As a part of the compensation package, this role may include eligible bonuses and commissions. For more information regarding iCare benefits, please click here.