Credentialing Specialist

Job Summary

Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all licensed clinical staff members who provide patient care. Responsible for ensuring providers are credentialed, appointed and privileged with health plans, hospitals and patient care facilities. Maintain up to date for each provider in credentialing databases and online systems ensure timely renewal of licenses and certification.

Duties and Responsibilities

Compiles and maintains current and accurate data for all providers
Completes provider credentialing and re-credentialing applications, monitors applications and follow-up as needed
Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
Maintains corporate provider contract files
Maintains knowledge of current health plan and agency requirements for credentialing providers
Sets up and maintains provider information in online credentialing databases and system
Tracks license and certification expirations for all providers to ensure timely renewals
Ensures practice addresses are current with health plans, agencies and other entities
Audits health plan directories for current and accurate provider information
Completes credentialing/re-credentialing application packets for hospital, insurance carriers and government programs. Applies for NPUI numbers for new providers, provides NPI numbers to physician offices and insurance carriers as requested. Enrolls new and updates existing providers in CAQH (on-line clearing house) according to guidelines
Initiates malpractice coverage application process for new providers
Coordinates with Accounts payable to ensure fees and premium payments are submitted for licenses, DEA certificates and malpractice coverage
Monitors and maintains database of all Continuing Medical Education credits obtained or programs attended by clinical staff, records additional certification earned by providers
Maintains confidentiality of provider information
Provides credentialing and privileging verification
Knowledge and understanding of credentialing process
Ability to organize and prioritize work and manage multiply priorities
Ability to research and analyze data
Ability to work independently with minimal supervision
Ability to establish and maintain effective working relationships with providers, management, staff and external contacts
Proficient use of Microsoft Office, Work, Excel and Access

Requirements and Qualifications

Associates Degree and Certified Provider Credentialing Specialist (CPCS) and minimum 2-3 Years Credentialing experience
High School with 5 Years credentialing experience. Medent a plus
Excellent verbal and written communication skills, ability to relate well with people of diverse backgrounds, training and experience
Proficiency with PC and medical practice software programs, Familiarity with credentialing requirements of hospitals and insurance carriers
Understanding of Malpractice insurance coverages and policies

Physical Demands

Position requires manual and finger dexterity and hand-eye coordination
Involves standing, sitting, and walking
Team member will occasionally be asked to lift and carry items weighing up to 10 pounds