SUMMARY

The Credentialing Specialist ensures that the plan provider network consists of providers that meet regulatory criteria to help minimize liability to the company and to maximize safety for plan members.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in the organization policies while meeting production goals.
• Communicates with health care providers to clarify questions and request any missing information.
• Updates credentialing software systems with required information.

• Requests re-credentialing applications from physician and organizational providers. Conducts follow-up on application requests, following department guidelines and production goals.
• Collaborates with internal and external contacts to ensure timely processing or termination of re-credentialing applicants.
• Completes data corrections in the credentialing database necessary for processing of re-credentialing applications.
• Reviews provider data management systems to determine provider status, as necessary in order to provide responses to external queries regarding practitioners’ or organization status.
• Conducts ongoing monitoring of provider expirables such as license and DEA certificates.
• Summarizes provider records for the Credentialing Committee monthly.
• Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
• Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found.
• Creates quarterly credentialing reports for reporting to the Quality Improvement Committee.
• Conducts ongoing transfer of physician and facility credentialing applications to the CVO for processing.
• Distributes weekly re-credentialing reports to the contracting department and sends notice of upcoming provider terminations.
• Creates and sends formal approval, requests for information and termination notices to providers based on Credentialing Committee decisions.
• Assists with Delegation Oversight audit reviews, tracking and reporting.
• Provides credentialing support and ongoing status updates to the contracting department.
• Submit supporting documentation for external and internal audits.

KNOWLEDGE, SKILLS AND ABILITIES

Responsible for coordinating assigned aspects of enterprise-wide credentialing process for practitioners and health delivery organizations according to company policy and procedures. Maintains a high level of confidentiality for provider information.

• Must be proficient with a variety of relevant computer programs and have excellent attention to detail.
• Knowledge of medical credentialing and privileging procedures and standards.
• Organizes information and data to identify/explain trends, problems, and their causes.
• Excellent verbal and written communication skills
• Proficient in Microsoft Office Word and Excel

EDUCATION

• College Degree Preferred

EXPERIENCE

• 5-10 years of experience
• Experience must be specific to credentialing activities in medical group practices, hospitals, managed care organizations, and CVOs.
• Experience can include a combination of credentialing oversight, direct privileging, delegation audits, compliance, CVO oversight and/or accreditation reviews.

LICENSE/CERTIFICATION

• Certified Provider Credentialing Specialist Certification Preferred