Credentialing Specialist

Job Title: Credentialing Specialist

Reports to: MEDBill

Supervises: N/A

Position Summary:

The Credentialing Specialist is responsible for helping to oversee the credentialing process for healthcare providers, ensuring compliance with billing regulations, and maintaining accurate records. This role involves collecting and verifying all required documents, ensuring compliance with state and federal regulations and maintaining accurate provider files.

Key Performance Areas & Key Performance Indicators:

Credentialing Process (25%):

• Obtain, review, and verify credentials for healthcare providers, including physicians, nurse, and other health professionals
• Ensure all credentialing activities comply with federal and state regulations, as well as organizational policies
• Develop and implement strategies to enhance the efficiency and effectiveness of the credentialing team
• Utilize CredentialMyDoc by HealthStream

Documentation of Verification of Accreditation, and Compliance (40%):

• 10 days from the time all information is received
• Verify licenses, certifications, educational background and various professional references
• Conduct primary source verification (PSV) to validate credentials
• Ensure all necessary documents are accurate and comply with national and state regulations, healthcare standards, and accreditation requirements
• Check that all licenses and/or certifications are up-to-date
• Staying up-to-date on credentialing requirements

Communication & Support (25%):

• Address and resolve any issues or discrepancies that may arise during the credentialing process- within 24 hours of discovery
• Responding to client inquiries within 24 hours
• Keeping an open line of communication with providers and fellow staff including weekly calls with the client, weekly updates sent to the client, and documenting within out Monday.com client board after every client interaction or update

Database Management: (25%):

• Maintaining comprehensive records of credentialed individuals and organizations
• This includes updating information, tracking expiration of licenses and/or certifications. Ensure all pending expirations resolved by no later than 15 days prior to expiration
• Ensuring confidentiality of documents with integrity and in compliance of HIPAA and other privacy laws

Minimum Qualifications:

Education:

• Associates Degree Required
• Bachelor’s Degree in Healthcare Administration, Business Administration, Healthcare Information Management, or related field
• Certified Provider Credentialing Specialist (CPCS) is a plus

Experience:

• 3-5 years of experience in healthcare administration, health information management, or related field
• Experience with credentialing processes, and knowledge of relevant software and database used in credentialing
• Excellent communication skills and interpersonal skills, with the ability to work well with healthcare professionals and other staff
• Exceptional attention to detail and overall organizational skills
• Proficiency with CredentialMyDocs, Dentrix, Vyne Trellis/Remote Lite, and other various software and databases is a plus

Competencies:

Operations Knowledge – Thoroughly understands the operational procedures for his/her position and how they affect or relate to other departments in the company. Serves as an expert for others.

Product Knowledge – Has a broad knowledge of the products and services offered. Is aware of the features and pricing of the products and services they support. Is able to recommend the appropriate product or service that will meet the customer’s needs.

Compliance Knowledge – Extensive understanding of general and department-specific regulations. Serves as a compliance resource for the team.

Sales & Service – Guides the team to achieve goals while ensuring excellent customer service. Maintains professional communication and positive customer relationships

Teamwork – Able to build morale and group commitments to goals and objectives; Balances team and individual responsibilities; Exhibits objectivity and openness to others’ views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Supports everyone’s efforts to succeed.

Computer Skills – Demonstrates a solid understanding of the technology utilized in his/her position. Consistently looks for ways to use technology to create efficiencies. Able to troubleshoot minor problems. May serve as an expert to others.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Strength- Employee must be able to stand and/ or sit for periods of time while waiting on customers. Employee may be required to walk, reach, lift, carry and bend. This job also requires the ability to lift and/or move up to 15 lbs. Occasionally, may need to lift more than 15 lbs.

Finger Dexterity- Employee will have to use fingers to make small movements, such as typing, picking up small objects, or pinching fingers together.

Talking- The ability to convey information accurately by speaking to customers and other employees

Hearing- Able to hear average or normal conversations and receive ordinary information.

Visual Abilities- Specific vision abilities used by this job are close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

*Employer reserves the right to change this job description at any time, should business needs arise.*