Credentialing Specialist

Job summary:

The Delegated Credentialing Specialist is responsible for overseeing our Delegated Contracts with the health plans both Medicaid and PPO. They are responsible for ensuring we are compliant with NCQA standards for health plan enrollment and re-enrollment for the providers. The role will be responsible for ensuring all requirements are met as well as ensuring accuracy of information for the assigned providers.

Summary of Essential Job Functions:

· Experience with Delegated Credentialing

· Knowledge and Understanding of NCQA Standards

· Knowledge and Understanding of Dental Medicaid/PPO Networks

· Maintaining Provider Monthly Monitoring/Reports

· Conducting Monthly CSC Audits

· Reviewing Monthly Preclusion Lists

· Conducting Monthly Credentialing Committee Meetings

· Completing Credentialing Committee Minutes

· Sending Monthly Rosters to Delegated plans to be loaded

· Maintaining Delegated Provider Files

· Maintaining Delegated Provider Rosters

· Maintaining Delegated Provider Initial Enrollment/Re-credentialing

· Completing Quarterly Reports for Delegated Contracts

· Completing and Meeting Annual Audit Requirements for Delegated Contracts

· Conducting Audit Requirements to obtain new Delegated Contracts

· Experience with Streamline Verify and Salesforce a plus

· Maintain and exhibit our core values of compassion, authenticity, talent and teamwork

· All other duties as assigned or apparent

Competencies:

· Quality - Applies feedback to improve performance, demonstrates accuracy and thoroughness, displays commitment to excellence, looks for ways to improve and promote quality, monitors own work to ensure quality

· Dependability - Commits to doing the best job possible, follows instructions, responds to management direction, keeps commitments, meets attendance and punctuality guidelines, responds to requests for service and assistance

· Adaptability - Adapts to changes in the work environment, changes approach or method to best fit the situation, manages competing demands

· Communications - Exhibits good listening and comprehension, expresses ideas and thoughts in written form, expresses ideas and thoughts verbally, keeps others adequately informed, selects and uses appropriate communication methods

Qualifications:

Education: High school diploma or equivalent

Experience: 2 years of experience in provider credentialing or enrollment on the provider or carrier side, preferably in a multi-entity, multi-state environment. Experience with Delegated Credentialing process.

Certifications: NA

Computer Skills: Computer Literate

Language Ability: Excellent verbal and written communication skills including the ability to remain calm during stressful customer or employee situations