Credentialing Specialist

Job Summary

Responsible for managing all aspects of the credentialing, re-credentialing, and privileging processes for licensed clinical team members who provide patient care. Ensure that providers are properly credentialed, appointed, and privileged with health plans, hospitals, and other patient care facilities. Maintain accurate, up-to-date provider information in credentialing databases and online systems, and ensure timely renewal of licenses and certifications.

Duties and Responsibilities

• Demonstrate our core values of being patient centered, team focused, service driven, accountable, and innovative every day.

• Compile and maintain accurate, up-to-date credentialing data for all providers.

• Complete credentialing and re-credentialing applications; monitor application status and follow up as needed.

• Maintain copies of current state licenses, Drug Enforcement Administration (DEA) certificates, malpractice coverage, and other required credentialing documents.

• Manage and update corporate provider contract files.

• Stay current on health plan and agency credentialing requirements.

• Establish and maintain provider information within online credentialing databases and systems.

• Track license and certification expiration dates to ensure timely renewals.

• Verify and update practice addresses with health plans, agencies, and other entities.

• Audit health plan directories to ensure provider information is accurate and up to date.

• Prepare and submit credentialing and re-credentialing application packets for hospitals, insurance carriers, and government programs.

• Apply for National Provider Identifier (NPI) numbers for new providers; provide NPI information to physician offices and insurance carriers as needed.

• Establish new and maintain existing provider information in Council for Affordable Quality Healthcare (CAQH) by following established guidelines.

• Initiate malpractice coverage applications for new providers.

• Coordinate with Accounts Payable to ensure timely payment of fees for licenses, DEA certificates, and malpractice coverage.

• Monitor and maintain a database of Continuing Medical Education (CME) credits and additional certifications earned by providers.

• Maintain confidentiality of all provider information.

• Provide credentialing and privileging verification as requested.

• Strong knowledge and understanding of the credentialing process.

• Ability to organize and prioritize work effectively and manage multiple priorities.

• Strong research and data analysis skills.

• Ability to work independently with minimal supervision.

• Excellent interpersonal skills with the ability to build and maintain positive working relationships with providers, management, staff, and external contacts.

• Evolve in your role when performing supplemental responsibilities as assigned.

Qualifications

Requirements and Qualifications

• Associates degree preferred; HS diploma or GED required.

• Certified Provider Credentialing Specialist (CPCS) preferred.

• Minimum 2 years’ experience as a Credentialing Specialist or in a similar role required.

• Demonstrated knowledge with EMR systems (e.g. Medent, Epic, or similar) is required.

• Comprehensive knowledge of medical practice software programs, credentialing requirements of hospitals, malpractice insurance coverages and policies and insurance carries preferred.

• Computer skills required with minimum proficiency in Microsoft Word, Excel, Outlook, and Teams.

Physical Demands

• Manual and finger dexterity and eye-hand coordination to enter data and operate office equipment.

• Corrected vision and hearing within normal range to observe and communicate with patients, providers, and staff.

• Frequently remaining in a stationary position, often sitting for prolonged periods working on a computer, telephone, copy/fax machine, and other office equipment.

• Occasional standing and walking required.

• Occasional lifting and carrying items weighing up to 10 pounds.

The pay range for this position is determined based on several factors, including the candidate’s years of experience, qualifications, training, licenses, designations, and the overall market conditions.

This job description does not state or imply that the duties and responsibilities listed are the only ones required of this position. Team members in this role will be required to perform other job-related duties at the discretion of the employer and may have additional duties assigned as necessary.

Excelsior Orthopaedics and Buffalo Surgery Center are committed to the full inclusion of all applicants. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information.