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