Credentialing Specialist

JOB OVERVIEW:

At the highest level, all employees of Spectrum of Hope must be enthusiastic, entrepreneurial, and committed to performing their job in an ethical and proper manner. The Credentialing Specialist is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing packages as required by commercial payers, Medicare and Medicaid, etc.

RESPONSIBILITIES:

• Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications


• Maintain internal provider grid to ensure all information is accurate and logins are available


• Update each provider's CAQH database file timely according to the schedule published by CMS • Apply for and renew annually all provider licenses.


• Complete revalidation requests issued by government payers


• Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid


• Complete re-credentialing applications for commercial payers


• Credential new providers and re-credential current providers


• Work closely with the Revenue Cycle Director and billing staff to identify and resolve any denials or authorization issues related to provider credentialing


• Maintainaccurate provider profiles on CAQH, PECOS, NPPES, and CMS databases


• Other duties as assigned

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

LANGUAGE SKILLS:

Ability to read, analyze, and interpret common information, reports, and other documents. Ability to respond to common inquires or complaints from customers, regulatory agencies, or company representatives. Ability to effectively present information to management.

PHYSICAL DEMANDS:

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

While performing the responsibilities of the job, the employee is required to talk and hear. The employee is often required to sit and use their hands and fingers, to handle or feel. The employee is occasionally required to stand, walk, reach with arms and hands, climb or balance, and to stoop, kneel, crouch or crawl. Additionally, the employee must be able to lift about 20 pounds.

WORK ENVIRONMENT:

While performing the responsibilities of the job, these work environment characteristics are representative of the environment the job holder will encounter. Reasonable accommodations may be made to enable people with disabilities to perform the essential functions of the job. This may be a remote position.

This job operates primarily in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

ESSENTIAL COMPETENCIES:

• Communication skills: Communication skills are essential because the interaction between credentialing specialists, coworkers, candidates, and clients is common. Credentialing specialists regularly communicate verbally to clarify procedures and respond to inquiries. As they may send emails to coworkers or applicants and create letters to clients, written communication is equally crucial.

• Technological skills: Credentialing specialists use technology to connect with others, create and deliver documents, and access and update information. They might employ technology to do research and create fresh protocols. Understanding how to use different software packages is essential for this position.


• Attention to detail and analytical skills: Your ability to pay attention to detail will help you execute your task effectively. It's essential to be attentive when analyzing documents or applications since as a credentialing specialist, you might need to analyze and approve a lot of material. Before approving an applicant's application, you might also need to make sure that the information in their file is accurate. The ability to analyze data and information, spot patterns and trends, and draw conclusions from those findings are known as analytical skills. When reviewing applications for credentials, assessing a trainee's performance in training sessions, and determining if a candidate has satisfied all certification requirements, credentialing professionals apply their analytical skills.


• Research skills: Research skills are essential because credentialing specialists often investigate the requirements for various credentials. They might research the requirements for a certain certificate, like one for a medical assistant, or they might research the requirements for a particular industry, like healthcare. They might also look into the qualifications needed for a certain job, like a medical assistant in a hospital.


• Customer service skills: You may engage with customers and give them the information they need to make an informed decision by using your customer service skills. Specialists in credentialing usually assist clients in understanding the process of obtaining credentials and the prerequisites for each certificate. You might use your customer service abilities to assist them in appreciating the worth of the credential and its advantages.


• Knowledge of medical terminology: The language used by medical professionals to explain bodily functions, diseases, and treatments is known as medical terminology. To effectively assess credentials and comprehend the information provided by applicants, credentialing professionals must have a clear understanding of medical terminology. When discussing patient records or treatment plans with other medical experts, medical terminology also facilitates communication.


• Knowledge of CMS. Medicaid Programs of Texas and credentialing regulations and/or the ability to research.

MINIMUM QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• GED, high school diploma, or any suitable equivalent.


• A minimum of 2 years of credentialing experience with hospital medical staff.


• (Recommended)Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS).


• Knowledge of medical credentialing procedures.


• Understanding of medical privileging standards.


• Excellent communication skills both in verbal and written form.


• Proficiency in Microsoft Office Word and Excel.


• Touch-typing skills expertise.


• Ability to focus for extended periods.