Credentialing Specialist

Job Description

Job Description

POSITION PURPOSE:

The Credentialing Specialist is responsible for credentialing and recredentialing all billable providers,

specialties, and facilities. Obtain access to the different MCO, Medicaid, and Medicare portals for

credentialing. The purpose is to credential the providers in a timely manner to enable CHI to bill for

services provided. Will provide support to the Director of Managed Care.

POSITION REQUIREMENTS / QUALIFICATIONS:

Education/Experience: Five years of experience in a healthcare-related position and/or Associate's degree or equivalent from a two-year college or technical school or equivalent combined experience. Experience working in a health care organization preferred Coding experience preferred

Licensure / Certification:

Must maintain current CPR certification from the American Heart Association. Certified

Professional Coder (CPC/CPCA) required.

Skills / Ability:

Knowledge of PC usage, Windows and Microsoft Office Applications, Database software,

spreadsheet software, word processing software.

Knowledge of healthcare and/or community health center industry and practices.

Knowledge of Managed Care Organizations and their different lines of business; Commercial,

Medicaid, Medicare, Exchange, Healthy Kids, etc.

CMS (Medicaid and Medicare)

Clear understanding of credentialing process

POSITION RESPONSIBILITIES

§ Primarily responsible for leading, coordinating, monitoring, and maintaining the credentialing

and recredentialing process

§ Primarily responsible for processing credentialing, re-credentialing and enrollment applications

of healthcare providers and sites, enforces regulatory compliance and adheres to quality

assurance standards.

§ Performs accurate and timely credentialing processes for all initial applications and

reappointments

§ Maintains current knowledge and ensures compliance with all accreditation, regulatory, health

plan standards, and CMS

§ Ensures all primary source verification is completed within the time-frame as allowed by

regulatory and accreditation entities.

§ Proactively works with center designees to acquire necessary materials and information.

§ Processes all appropriate queries for licensure, or any appropriate regulatory credentialing

requirements, and maintains documentation in the database

§ Collects and verifies sensitive provider data through confidential sources and maintains a

credentialing database

§ Performs analysis and appropriate follow-up of all applications

§ Identifies issues that require additional investigation and evaluation, validates discrepancies and

ensures appropriate follow up

§ Ensures proper escalation of any issues impacting the completion of the application(s) or

concerns brought forth by center/stakeholder

§ Completes accurate and timely data entry into the database to ensure consistency and integrity

of the data

§ Tracks license and certification expirations for all providers to ensure timely renewals.

§ Prepares files for presentation to leadership and the credentialing committee

§ Ensures timely and effective communication with centers and stakeholders on the progress of all

applications, addresses any inquiries set forth

§ Provides monthly reports of the credentialing and enrollment status to centers on the status of

all assigned providers

§ Assists with internal auditing functions and performs peer evaluations as assigned

§ Audits health plan directories for current and accurate provider information.

§ Supports credentialing committee meetings as needed

§ Subject Matter Expert on Delegated and 3rd Party Payers

§ Internal Team Resource for Special Projects and Assisting Team Members who need additional

credentialing application help

§ Other duties as assigned

WE ARE AN EQUAL OPPORTUNITY EMPLOYER