What are the responsibilities and job description for the Credentialing Specialist I position at Blue Cross of Idaho?
Our Credentialing Specialist supports departmental activities to ensure quality in conducting, maintaining, and communicating physician and facility credentialing, monitoring, and source verification to ensure contracting providers meet credentialing standards. Serves as a resource to, and collaborates with, others to ensure high quality practitioners and facilities are accessible for members. Provides education and maintains relationships with providers regarding credentialing standards and processes.
This is an onsite role located at our Meridian, Idaho campus and will offer a hybrid work schedule.
We're looking for Credentialing Specialist with:
- 2 years within health industry setting such as billing, credentialing, or state medical regulatory agency
- Education: High School or equivalent
What a day would look like:
- Conducts and maintains provider credentialing and communicates with providers regarding status/information/credentialing requirements.
- Obtains and evaluates information regarding practitioner sanctions, complaints, and adverse data to ensure compliance.
- Analyzes application and supporting documents for completeness and informs the practitioner of the application status, including the need for any additional information.
- Maintains all credentialing documentation, including sensitive provider background information, to ensure Company, Federal, and State regulatory requirements are met.
- Compiles, evaluates, and presents provider-specific data collected for review and presentation to Credentialing Committee. Tracks and reports on follow-up items to include notification, appeal, and hearing processes.
- Collaborates with key departments to ensure provider contracting, quality and remedial action plans are implemented, tracked, and reported.
- Expresses thoughts clearly, concisely, and effectively both verbally and in writing.
- Makes recommended changes to policies, procedures, and/or processes and ensure they meet company and regulatory requirements.
- Meets department metric targets to maintain service level for providers.
- May perform delegation oversight.
- May conduct site visits during the credentialing process.
- May report adverse credentialing actions to appropriate agencies.
- May prepare and provides reports/documentation for audits requested by regulating bodies.
- Establishes productive, cooperative relationships with peers, management, and stakeholders both internal and external to the organization.
- Performs other duties and responsibilities as assigned.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
