Patient Accounts - Credentialing Specialist

Description

Job Summary:

 The Credentialing Specialist is responsible for managing the credentialing, recredentialing, licensing and payer enrollment processes for healthcare providers to ensure uninterrupted patient care and compliance with all regulatory requirements. This role requires meticulous attention to detail and the ability to work collaboratively with internal teams, providers, and payer representatives. As our business continues to grow, the scope of responsibilities may evolve to meet organizational needs. 

Duties and Responsibilities:

 1. Accurately maintain and update provider credentialing and payer enrollment records in all areas to include all governmental    agencies and commercial insurance plans.

2. Manage and monitor all aspects of the payer enrollment and re-enrollment process to ensure timely and successful participation with contracted insurance plans.

3. Analyze provider credentialing and enrollment files for completeness, accuracy, and compliance; identify and resolve any discrepancies or deficiencies.

4. Collaborate closely with internal teams (billing, contracting, operations, and clinical) to align credentialing and payer enrollment processes with organizational timelines.

5. Develop and maintain positive working relationships with payer representatives, providers, and third-party organizations to expedite application processing and issue resolution.

6. Serve as a resource for providers by responding to inquiries via phone, email, or internal communication channels in a timely and professional manner.

7. Track application status, monitor expirable, and ensure compliance with federal, state, and payer-specific regulations.

8. Assist with audits, special projects, and process improvement initiatives related to credentialing and payer enrollment.

Requirements

Education: Requires high school diploma or equivalent. Associate degree preferred. 

Experience: 2 years in provider credentialing.  Experience using credentialing/enrollment software (Modio) preferred. 

Skills: Excellent grammar and communication skills. Computer skills, including all Microsoft Office software to include Word and Excel. Effective oral and written communication skills. Ability to type 45 wpm, use a 10-key calculator. Attention to detail and good record-keeping skills a must.

Knowledge:  Working knowledge of payer enrollment processes, timelines, and requirements for commercial and government insurance plans. 

Abilities:  Strong organizational skills and ability to manage multiple applications and deadlines simultaneously.  Proficiency with Microsoft Office Suite (Excel, Word, Outlook) and comfort navigating web-based portals.  Demonstrated ability to maintain strict confidentiality and comply with HIPAA regulations.  Ability to work independently and as a collaborative team member in a fast-paced, evolving environment. 

OSHA Categories: Category III - Normal routine involves no exposure to blood, body fluid or tissue, and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid

Physical Requirements

Light Work - Exerting up to 20 pounds of force frequently, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. If the use of arm and/or leg control requires exertion of forces greater than that of sedentary work and if the worker sits most of the time, the job is considered light work.

• Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
• See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
• Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
• Stoop, kneel, crouch, or crawl (Position self (to), Move)
• Walk (Move, Traverse)
• Stand or Sit (Stationary Position)
• Pushing or Pulling
• Repetitive Motion
• Reaching
• Taste/Smell (Detect, Distinguish, Determine)
• Exposure to Dust
• Noise