Credentialing Specialist

Description

SUMMARY

The Credentialing Specialist evaluates, analyzes, and coordinates all aspects of the credentialing and recredentialing process and provides integral support to operations by enabling timely onboarding of healthcare providers.  The Credentialing Specialist fully manages credentialing applications, files, and historical records and ensures that medical staff members maintain current credentials and licenses to work legally in their field or specialty. The Credentialing Specialist is responsible for payor enrollment into various IPAs, health plans, state programs, and Medi-Cal/Medicare (CMS) while simultaneously tracking enrollment status.   

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

1. Determines priorities and best method of completing daily workload to ensure that all responsibilities are carried out in a timely manner.
2. Performs all job functions in a professional and courteous manner. This includes answering all general phone calls timely and providing excellent customer service to internal and external customers.
3. Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with federal, state, local and organizational regulations, guidelines, policies, and standards.
4. Conducts primary source verification, collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards and organizational criteria.
5. Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to leadership for sound decision making in accordance with credentialing policies and procedures, federal, state, local and government/insurance agency regulations.
6. Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, HRSA requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
7. Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures. Files and maintains confidential credentialing and privileging files.
8. Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
9. Participates in the development and implementation of process improvements for the system-wide credentialing process; prepares reports as required by regulatory and accrediting agencies, policies and standards.
10. Communicates clearly with providers, their liaisons, medical staff leadership, the Credentialing Committee, and administration, as needed to provide timely responses upon request on day-to-day credentialing and privileging issues as they arise.
11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
12. Composes, types and edits correspondence and reports, creates or modifies fillable forms, and may compose routine correspondence in ready form for executive’s signature. Handles highly-sensitive information with discretion and in a professional and exemplary manner.
13. Monitors approaching deadlines and plans accordingly to keep records current.
14. Follows-up on appointment letters, processes requests for additional privileges and explains the reasons/s for the condition/limitation/deferment. Maintains forms and templates, and credentialed staff information.
15. Drives to various clinic and administrative locations to collect signatures, deliver documents, mail or ship, and/or collect forms, as needed.
16. Collaborates with other departments and supports intradepartmental initiatives.
17. Must be willing and able to work at all locations as needed to meet patient care needs.
18. Must be willing and able to work all business hours including occasional evenings and weekends.
19. Performs all other duties as assigned.

Qualifications

EDUCATION/EXPERIENCE

1. High school diploma, GED, or at least 5 years of experience directly related to the duties and responsibilities specified.
2. Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Superb organizational skills, strong sense of urgency, ability to plan ahead, and self-administer workload to meet deadlines.
2. Adaptable, detail oriented, and dependable.
3. Ability to work with minimal supervision and relay consistent updates to supervisor(s) periodically.
4. Critical thinking and analytical skills. Capable of identifying areas of improvement and problem-solve accordingly.
5. Ability to communicate effectively both orally and in writing with internal and external clients and collaborators in a timely manner.
6. Ability to work collaboratively and independently.
7. Advanced skills in computerized spreadsheeting and database management.
8. Demonstrated advanced working knowledge in computer applications including Microsoft Excel, Power Point, Word, Outlook, Teams, and SharePoint, online applications, and office equipment. Experience using databases and/or Paycom preferred.
9. Typing speed: 50 wpm or above.
10. Must have own automobile, valid California driver’s license, and active automobile insurance.

Salary : $24 - $36