Credentialing Specialist

WHAT WE DO:

Advanced Wound Therapy is revolutionizing wound care in Oklahoma with our specialized mobile healthcare services. We partner with Home Health, Hospice, Nursing Home, and Assisted Living facilities to deliver exceptional wound management directly to patients. Our commitment to excellence is reflected in our vibrant company culture, which emphasizes servant leadership and prioritizes high-quality patient care.

JOB DESCRIPTION:

We are seeking a detail-oriented and highly organized Credentialing Specialist to manage and maintain provider credentials, ensuring compliance with regulatory and insurance requirements. This role is responsible for provider onboarding, credentialing, re-credentialing, and contracting, while acting as a liaison between our organization and insurance entities. The ideal candidate will have excellent communication skills, a strong understanding of credentialing processes, and the ability to track and verify provider information efficiently. A successful Credentialing Specialist will be proactive in managing expiring documents, staying up to date on changing policies, and ensuring all credentialing activities meet industry and company standards.

KEY RESPONSIBILITIES:

Provider Management

• Maintain and update provider information in CAQH and other credentialing databases.
• Oversee provider re-credentialing, re-certification, and ongoing verification of credentials.
• Verifying the accuracy of qualifications, including medical licenses, board certifications, and education. This also includes checking employment history and professional references.
• Communicate with independent physician associations (IPAs) to facilitate provider credentialing and compliance.
• Track and manage expiring documents, ensuring timely renewals and compliance.
• Conduct routine provider screenings and monitor any necessary updates.
• Work closely with HR, compliance officers, legal teams, and other departments to ensure all credentialing standards are met and upheld.

Insurance Communication

• Serve as the primary liaison between AWT and insurance entities.
• Stay informed of policy updates and industry changes, ensuring compliance.
• Efficiently manage requests from insurance carriers regarding credentialing status and documentation.
• Conducting internal audits to ensure the organization is meeting credentialing standards and generating reports for management or regulatory purposes.
• Retrieve and verify required provider information, responding to audits and compliance checks.

Initial Credentialing and Contracting

• Facilitate provider onboarding, ensuring all necessary documentation is collected and verified.
• Oversee the entire credentialing process, from application to approval.
• Managing the application process for new providers, from gathering required documents to submitting applications and follow-up.
• Entering and maintaining up-to-date records for healthcare providers in credentialing systems and databases.
• Verifying credentials through primary sources such as medical schools, licensing boards, and other authoritative sources to ensure accuracy.
• Strong understanding of healthcare laws and regulations, such as HIPAA, Joint Commission standards, NCQA, and other accreditation bodies, to ensure compliance in the credentialing process.
• Manage provider and group contracting with insurance carriers.
• Ensure all contracts and credentialing activities align with company policies and industry regulations.
• When discrepancies or red flags arise (such as an expired license or missing certification), investigating the issue and following up to resolve it.

QUALIFICATIONS:

Education & Experience

• Associate’s or Bachelor’s degree preferred.
• 2 years of experience in credentialing, provider enrollment, or a related healthcare role.

Skills & Attributes

• Strong knowledge of CAQH, provider credentialing processes, and insurance requirements.
• Excellent attention to detail and ability to track multiple deadlines.
• The ability to evaluate and interpret information from background checks, education verification, licensure, and certifications to determine a provider’s qualifications.
• Strong communication and interpersonal skills to liaise with providers and insurance entities, and be able to provide excellent service, making the process smoother for everyone involved.
• Proficiency in database management and document tracking systems.
• Problem solving skills when issues (like discrepancies in documents or delays in verification) come up, and this person must be able to find solutions efficiently and without significant direction from superiors.
• Ability to work independently and manage time effectively.