Provider Privileging Specialist (Remote)

Title: Provider Privileging Specialist
Location: USA/Remote
Reports to: Director of Credentialing
FLSA Classification: Non-Exempt
Full-Time
Salary Range: $28-$32
Starting pay varies based on location and experience, in compliance with specific state wage regulations. Competitive rates tailored to your geography and expertise.

Position Overview:

The Provider Privileging Specialist oversees the onboarding, credentialing, enrollment, and submission of facility privileging applications. This role requires a blend of expertise, strategic thinking, organizational, communication, and multi-tasking skills to manage cross-functional tasks.

Key Responsibilities:

Provider Onboarding/Credentialing:

• Validate and maintain licensing, credentials, and insurance records using applicable websites for verification for various medical professionals according to NCQA & TJC standards.
• Monitor license and credential expiration dates and advise staff members of required updates.
• Work with providers and practice administrators to obtain necessary documents for new provider onboarding.
• Work directly with providers to obtain malpractice history explanations when applicable.
• Recognize, investigate, and validate discrepancies and adverse information obtained from applications, primary source verifications, or other sources.
• Conduct professional follow-ups for outstanding applications, perform primary source verifications, and obtain clinical activity documentation.
• Complete required searches such as OIG, Opt-Out, and NPDB for presentation to the Credentials Committee and governing bodies.
• Track application statuses, follow up on missing information, and ensure credentialing files are complete, accurate, and up to date.

Privileging:

• Prepare facility applications for medical professionals seeking privileging or reappointments.
• Collaborate with providers and practice administrators to gather required documentation, including credentials, medical malpractice history, and vaccination/health records.
• Maintain consistent communication with providers and credentialing contacts to ensure timely and accurate credentialing completion.
• Maintain logs, records, and documentation required for provider credentialing and re-credentialing, ensuring compliance with NCQA standards.
• Verify physician/provider credentials for managed care plans, communicating with health plan representatives as needed.
• Follow up with facilities and managed care companies to ensure prompt credentialing and enrollment.
• Complete privileging applications, payer applications, link letters, and rosters per managed care organization specifications.
• Maintain relationships with external facilities, providers, clients, and managed care organizations.

Provider Enrollment:

• Coordinate all managed care credentialing activities to ensure provider participation status.
• Prepare credentialing and re-credentialing applications for submission to managed care companies and facilities for privileging.
• Follow up with managed care companies to ensure timely credentialing and enrollment.
• Maintain relationships with external facilities, providers, clients, and managed care organizations.
• Perform other duties as assigned.

Skills and Competencies:

• Strong analytical thinking and attention to detail.
• Ability to manage multiple projects and meet deadlines.
• Strong technical aptitude and ability to learn new systems quickly.
• Collaborative mindset with a focus on team success.

Education and Experience:

• 3 years of credentialing experience required; NCQA, CPCS, or CPCSM certification preferred.
• Associate’s Degree and 3 years’ experience performing data collection or data analysis using complex database software systems.
• A combination of education and experience may be considered.
• Experience with credentialing software and database management for efficient tracking and reporting.
• Familiarity with PECOS, NPPES, NPDB, legal regulations, state requirements, TJC, and NCQA guidelines to ensure compliance.

Additional Information:

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities, and working conditions may change as needs evolve.

Coronis Health is committed to creating a diverse and inclusive environment where all employees are treated fairly and with respect. We are an equal-opportunity employer, providing equal opportunities to all applicants and employees regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other protected characteristic. We welcome and encourage applications from candidates of all backgrounds.