Sr Licensure and Credentialing Specialist

Description

The Senior Licensure & Credentialing Specialist reports to the Chief Contracting Officer and will be responsible for all aspects of the credentialing, recredentialing, and licensure for all facilities for Medicare, Commercial Payers, and Medicaid programs. They will ensure providers are credentialed, appointed, and privileged with health plans, Medicare, state Medicaid programs, and maintain up-to-date data for each location in credentialing databases and online systems; ensuring timely renewal of licenses and certifications. This is a full-time, Exempt level, Remote position.

ESSENTIAL FUNCTIONS:

• Process initial credentialing and re-credentialing applications
• Create and maintain licensing, credentials and insurance records for Medicare, Medicaid, and Commercial Payers
• Enroll and revalidate Medicare & Medicaid
• Support development of internal credentialing processes
• Complete credentialing applications
• Identify discrepancies in information and conducting follow-ups
• Maintain internal and external databases (CAQH, PECOS, NPPES)
• Respond to health plan provider inquiries
• Responsible for follow-up after submission to ensure that health plans have appropriately processed the request, and that provider information shows correctly on the health plans website
• Audit Health Plan Directory
• Conduct research on updated state and federal regulations and policies
• CAQH creation and maintenance experience
• Perform provider roster reconciliation
• Monitor license and credential expiration dates and advise staff members of required “renew by” dates
• Provide internal and external support for health plan issue resolution

Qualifications

• High school diploma/GED required
• 5 years of experience working for a health maintenance organization, health plan, provider office and/or in another health insurance-related setting
• Experience with Managed Care Organizations (MCO's) and Centers for Medicare & Medicaid Services (CMS) credentialing and registration requirements
• Experience with provider credentialing process, timeframes and appeal options; health plan design, contracting, plan policies and procedures; MCO reporting and recordkeeping requirements.
• Ability to build professional cross functional working relationships among all levels of the organization.
• Ability to make valid judgments, formulate recommendations or action plans, and evaluate the effects of decisions and actions.
• Intermediate computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes
• Team player that develops strong collaborative working relationships with internal partners and can effectively engage and ability to build consensus among cross-functional teams