Credentialing Specialist

Credentialing Specialist

Responsible for processing privileging/credentialing/contract applications for organization, sites and providers, in accordance with department expectations. Works closely with Chief of Clinical Affairs and Clinical Officers, Chief Revenue Officer, Billing Manager, and Credentialing Team Lead, ensuring the privileging/credentialing/contracting process is completed correctly, within established timeframes. This will include, but not limited to responsibility of contracting with health plans, privileging/credentialing new and established health care providers/sites, and maintenance of information to include primary source verification, follow up, data collection, data entry, and document review.

DUTIES AND RESPONSIBILITIES:

• Initiates and reviews privileging/credentialing/contract applications, conducts background checks and maintains primary source and federal loan verifications and queries, ensuring completeness, identifying discrepancies and potential issues, maintaining compliance with Center policies and procedures, federal and state regulatory and accrediting agencies.
• Responsible for timely and accurate multi-system data entry of health plan/location/provider additions, deletions and changes. Ensures that all providers are privileged/credentialed and re-privileged/re-credentialed with the organization's contracted health plans, and in accordance with departmental policies and procedures.
• Maintains a working knowledge of privileging/credentialing/contracting policies, procedures and processes, in an effort to provide cross-functional departmental support to the business office and provider services team on an as-needed basis.
• Maintains scanned copies of all health plan contracts/agreements/amendments/correspondence, receives daily mail from health plans and responds to requests related to credentialing and contracting.
• Prepares and distributes reports in accordance with privileging/credentialing and departmental policies and procedures utilizing credentialing software; incorporating paperless processes.
• Attends privileging/credentialing committee meetings. Provides excellent internal/external customer service via telephone, fax, or face-face contact to assist in expediting the necessary steps to complete the privileging/credentialing process.
• Reviews payment rates of contracts with Billing Manager when discrepancies are identified with health plan payments. Communicates with health plans' provider representatives to ensure any issues are resolved in a timely manner and works special projects related to reimbursement issues.
• Maintains a working knowledge of HRIS and credentialing systems, providing support for maintenance and data entry as needed.
• Maintains knowledge of National Committee for Quality Assurance (NCQA), Joint Commission and CMS regulatory requirements.
• Performs other related duties as assigned.

JOB QUALIFICATIONS:

• High school diploma or equivalent
• Minimum two years experience preferred in health care privileging/credentialing/contracting
• Experience with Credentialing Accreditation by Joint Commission or NCQA highly preferred
• Demonstrated working knowledge of the health care privileging/credentialing/contracting industry, including medical-legal issues and laws, regulatory agencies, and other national standards preferred
• Knowledge of business office operations, proficient in Microsoft Office Suite
• Able to work with minimal supervision and works well in both individual and group environment
• Ability to communicate effectively both orally and in writing with employees and the general public, to maintain confidentiality in daily operations, and to conduct daily duties in a professional appearance and manner

PHYSICAL ACTIVITIES AND REQUIREMENTS:

• Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects.
• Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly.
• Hearing: Able to hear average or normal conversations and receive ordinary information.
• Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers.
• Visual: Average, ordinary, visual acuity necessary to prepare or inspect documents or other materials.
• Physical: Sedentary work; sitting most of the time. May have to lift folders, files, papers, audio/video equipment, and other such items weighing up to approximately 25 lbs.

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.