Credentialing Specialist

JOB TITLE: Credentialing Specialist FLSA STATUS (Exempt/Non-Exempt): Non-Exempt SUPERVISION RECEIVED: Reports to Credentialing Manager SUPERVISION EXERCISED: None GENERAL STATEMENT OF DUTIES Responsible for performing day-to-day credentialing, recredentialing, licensing, privileging, and payer enrollment activities for Premier and Philadelphia Hand to Shoulder Center physicians and other healthcare providers.Ensurescredentialingapplications and supporting documentation are complete,accurate, and submitted within requiredtimeframes. Maintains current provider information within credentialing systems, monitors licenses, certifications, and other expirable credentials, and providestimelyfollow-up with physicians/providers, hospitals, health plans, and other organizations. Works closely with the Credentialing Manager and internal departments to supporttimelyprovider onboarding andmaintainongoing credentialing compliance. ESSENTIAL FUNCTIONS Completes and processesinitialcredentialing and recredentialing applications for physicians and other healthcare providers. Collects, reviews, andmaintainsrequired credentialing documentation, including professional licenses, board certifications, DEA registrations, professional liability insurance, education, training, work history, and other required credentials. Performs primary source verification of provider credentialsin accordance withapplicable requirements. Obtains and reviews National Practitioner Data Bank (NPDB), Office of Inspector General (OIG), state licensing board, and other applicable verification or sanction information. Completes andmaintainsprovider enrollment applications for Medicare, Medicaid, commercial health plans, and other applicable payers. Coordinates hospital and facility credentialing,privileging, and reappointment applications, as applicable. Maintainsaccurateand current provider information within CAQH and other applicable credentialing, payer, hospital, and provider databases. Tracks and monitors provider licenses, DEA registrations, board certifications, professional liability insurance, and other expirable credentials to ensuretimelyrenewal. Contactsphysicians/providers to obtain outstanding applications, signatures, attestations, documentation, and other informationrequiredto complete credentialing activities. Provides consistent andtimelyfollow-up on outstanding credentialing and recredentialing applications. Communicates credentialing status, outstanding requirements, and potential delays to the Credentialing Manager and otherappropriate stakeholders. Identifiesincomplete, inconsistent, or potentially concerning credentialing information and escalates issues to the Credentialing Manager for review. Ensures hospitals, health plans, medical groups, and other applicable entities receive required provider demographic and practice updates. Processesproviderdemographic changes, additions, terminations, and other updates with applicable payers, hospitals, facilities, andcredentialingorganizations. Assistswith provider network termination activities when providers leave the organization. Maintainsaccurateelectronic credentialing files and ensures documentation is appropriately filed, scanned, indexed, andentered intoapplicable credentialing systems. Ensures provider credentialing records are complete,accurate, current, confidential, and audit-ready. Monitors credentialing and enrollment timelines and follows up with payers, hospitals, and other entitiesregardingpending applications. Assistswith researching and resolving credentialing and payer enrollment issues that mayimpactprovider billing or reimbursement. Partners with Revenue CycleManagement toresearch credentialing-related claim denials and provider enrollment discrepancies as directed. Supportsthe provideronboarding process by completing credentialing activities within established timelines and communicating potential barriers or delays. Responds to credentialingverificationrequests and requests for provider documentationin accordance withorganizational procedures. Assistswith internal and external credentialing audits and provides requested documentation. Maintains the privacy and confidentiality of provider professional and personal information obtained in the performance of job responsibilities. Cross-trainson credentialing functions and provides back-up support to other members of the Credentialing Department as needed. Establishes andmaintainseffective communication with physicians/providers, hospitals, health plans,credentialingagencies, and internal departments. Participates in department meetings, training, process improvement initiatives, and special projects as requested. Performs other duties as assigned. EDUCATION High school diploma or GEDpreferred. Associate's orbachelor's degree in Healthcare Administration, Business Administration, or a related field preferred. Certified Provider Credentialing Specialist (CPCS) certification preferred. EXPERIENCE Minimum of two (2) years of experience in healthcare credentialing, provider enrollment, medical staff services, or a related healthcare administrative function preferred. Experience processing physician and other healthcareprovidercredentialing and recredentialing applications preferred. Experience with payer enrollment, CAQH, Medicare, Medicaid, and commercial health plans preferred. Experience working in a physician practice, medical group, hospital, or outpatient healthcare organization preferred. KNOWLEDGE Knowledge of provider credentialing and recredentialing processes. Knowledge of credentialing documentation and primary source verification requirements. Knowledge of professional licensing, DEA registration, board certification, professional liability insurance, and other provider credential requirements. Knowledge of provider enrollment processes and payer requirements. Knowledge of CAQH and applicable governmental and commercial payer enrollment systems. Knowledge of credentialing timelines andproviderexpirable requirements. Knowledge of NPDB, OIG, state licensing board, and otherapplicable credentialingverification resources. Knowledge of credentialing databases and Microsoft Office applications. SKILLS Excellent organizational and time-management skills. Strong attention to detail and accuracy. Excellent verbal and written communication skills. Skill in managing multiple credentialing files, applications, and deadlines simultaneously. Skill in reviewing documentation for accuracy and completeness. Skill inidentifyingmissing or inconsistentcredentialinginformation. Skill in following up effectively with physicians/providers and external organizations. Strong problem-solving skills. Skill inestablishingeffective working relationships with physicians/providers, staff, payers, hospitals, andcredentialingagencies. Skill inmaintainingconfidentiality and handling sensitive information appropriately. ABILITIES Ability to independently process credentialing and recredentialing applications from initiation through completion. Ability to manage multiple provider files and competing deadlines. Ability to accurately collect, verify, enter, andmaintaindetailed provider information. Ability to follow established credentialing policies, procedures, and regulatory requirements. Ability toidentifycredentialing deficiencies or delays and elevate concerns appropriately. Ability to communicate professionally and effectively with physicians/providers, hospitals, payers, credentialing agencies, management, and staff. Ability to organize and prioritize work to meet credentialing, enrollment, and renewal deadlines. Ability to exercise sound judgement andmaintainstrict confidentiality. Ability to work effectively both independently and as part of the Credentialing Department. ENVIRONMENTAL WORKING CONDITIONS Normal office and healthcare administrative environment. Occasional travel between Premier and Philadelphia Hand to Shoulder Center locations as needed. PHYSICAL/MENTAL DEMANDS Requires sitting, standing, walking, and occasional bending associated with a normal office environment. Requires manual dexterity for computer, telephone, and other office equipmentuse. Requires sustained attention to detail and accuracy when reviewing and enteringprovidercredentialing information. Requires the ability to manage multiple priorities and time-sensitive credentialing deadlines. ORGANIZATIONAL REQUIREMENTS HOPCo'sMission, Vision, and Values must be acknowledged and adhered to. Completes all required organizational training and education. Maintains compliance withallpolicies and procedures. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr