Credentialing Specialist - Hybrid

Overview

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Credentialing Specialist performs all functions in support of onboarding to include initial credentialing,recredentialing, and credentialing monitoring requirements including, but not limited to, performing acomprehensive quality review of “non- standard” credentialing/re-credentialing, which includes those files with questionable clinical, quality and/or business issues, provider license monitoring, updates tocredentialing database from internal reports and notifications, and initiation of CAQH application process for initial credentialing, initiation of recredentialing process. Additionally, this position is responsible for assisting with the routing of files to and from the medical advisor and to and from the credentialing committee.

Responsibilities

• Distribute packets for CAQH data, payer documents and MARs packet to new hires• Primary Source Verification of initial credentialing/re-credentialing files according to NCQAStandards• Appropriately identify and forward applicant initial and re-cred files which do not meet “standard”requirements to medical advisor and/or credentialing committee, according to establishedguidelines. Notify timely if any issues are identified and determine next course of action.• Enter and maintain clinician demographic and credentialing information in credentialing database(IntelliCred) obtained through credentialing application, primary source verifications, internalreports, and notifications• Facilitate creation and/or updating of CAQH applications for initial credentialing andrecredentialing when clinician is onboarding through new hire process or new businessdevelopment process.• Participate in credentialing committee meetings to assure committee members have necessaryinformation, explain questionable information contained in file and act as overall resource forgeneral credentialing processes• Conduct license monitoring process for all providers in accordance with licenses, certificate andboards monitoring policy, to include initiation of letters, reports, and primary source verification ofrenewals• Identify issues in clinician's file that require committee review - create a medical review file and• Obtain all requested data elements per committee chairman's request for file to be completed topresent to committee.• Works with External Payer Credentialing and Medicare Enrollment teams on various credentialingprojects and internal interfacing processes.• Submit information required to risk department to obtain COI prior to start date and in order tocomplete file with high quality work in a quick and efficient turnaround time.• Collaborate with recruiting, onboarding, risk management and hiring manager to complete prehireclearance and credentialing process for start date to be confirmed

This job description is not designed to cover or contain a comprehensive listing of activities, duties orresponsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Qualifications

Education Level: High School Diploma or GEDMajor:

Degree must be from an accredited college or university.Education Details:

Certifications and/or Licenses:• Certified Professional Credentialing Specialist (preferred)

Experience in lieu of required education is acceptable: YesContinuing education is required to maintain license and to perform job: No

Customarily has at least the following experience: 1 year

• Minimum 1-2 years direct experience in credentialing required - CAQH experience preferred• Certified Professional Credentialing Specialist certification preferred• Knowledge of credentialing software (IntelliCred) is preferred• Working knowledge of NCQA, URAC and/or AAHC credentialing standards