Credentialing Specialist

Position Summary The Credentialing Specialist is responsible for supporting the process functions related to the credentialing and re‑credentialing of health plan providers (including facilities) to ensure they meet the necessary requirements and credentialing standards/regulations (CMS/NCQA/DoD) for acceptance and continued participation as a network provider of Martin’s Point Health Care’s multiple health plans/product lines. The individual also assists with the daily management of an external Credentialing Verification Organization ("CVO") that provides provider and facility primary source verification services to Martin’s Point Health Care (MPHC). Key Outcomes Maintains up‑to‑date knowledge of NCQA, CMS standards, and DoD requirements as they relate to the credentialing function, as well as MPHC Credentialing and Network Management departmental policies and procedures, and applies them appropriately based on the provider’s contractual status. Receives primary source verification information from CVO. Acts as point person between MPHC and CVO. Determines if detailed Credentials Committee review is required based on “exception” criteria. Conducts primary source verification of credentials, as required, through utilization of credentialing software interfaces, direct contact, and/or industry approved verification websites. Responsible for the accuracy and integrity of credentialing data. Ensures the timeliness of credentialing/re‑credentialing verification/processing. Enters provider data and verification information into credentialing software database and adds appropriate documentation to the provider credentialing file based on standard departmental format and policies and procedures. Collaborates with other departments to define/clarify provider applicant status and demographics, as well as streamline application processes and information exchanges, and ongoing monitoring to ensure the provider continues to meet participation criteria. Reviews exceptions/red flag cases to ensure all information is obtained to present cases for peer review. Audits credentials files/processes to ensure compliance with regulatory and accreditation standards, providing education/improvement activities as appropriate. Responsible for monthly Credentials Committee preparation and follow‑up, as applicable. Manages the Credentials Committee process by preparing provider’s files, photocopies and collates provider packages for each committee member. Prepares routine provider/facility lists for the committee chair to sign. Responsible for managing the Ongoing Monitoring process between credentialing cycles—tasks include but are not limited to querying state agencies to gather information on providers with sanctions, tracking network providers with sanctions, and if applicable, reviewing cases with the Credentialing Committee chairperson. Begins preparation of incoming initial applications with Network Management Provider Operations Representatives to pass on to CVO, to ensure applicant meets the established internal participation criteria for acceptance. Compiles data and maintains databases/spreadsheets to support operational tracking needs. Provides filing of documents, letter and mailing production, report generation, and support on special projects. Maintains ongoing relationship with network‑wide credentialing delegates, including monthly and ad‑hoc reporting, agreement review, on‑site file audits, and policy and procedure review. Preparation and participation in NCQA on‑site file audits. Education / Experience Bachelor’s Degree or equivalent combination of relevant education and experience. 3 years relevant experience required. CPCS certification through the National Association Medical Staff Services preferred but not required. Skills, Knowledge, and Competencies (Behaviors) Strong proficiency in Microsoft Office and the ability to learn applications that support the credentialing process. Ability to manage, organize, and prioritize workload in a timely, accurate manner. Excellent communication and interpersonal skills and ability to manage internal and external relationships. Knowledge of NCQA, CMS, and DoD credentialing standards. Commitment to continue credentialing training and education. Strong attention to detail. Other Information This position is not eligible for immigration sponsorship. Equal Opportunity Statement We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact View email address on click.appcast.io. #J-18808-Ljbffr