CREDENTIALING SPECIALIST

SUMMARY OF RESPONSIBILITY:

This position is responsible for all aspects of credentialing and re-credentialing for the practitioners affiliated with the organization, in compliance with NCQA guidelines as well as various delegated credentialing agreements and other industry standards.  Responsible for ensuring all participating practitioners are enrolled with contracted health plans.  Maintains current and accurate data for each practitioner in credentialing database and other online systems and ensures timely and accurate renewals of licenses, certifications, and liability coverage. 

 This role is located at the company's headquarters in Windsor, CT, and operates in hybrid/remote environment.

 ESSENTIAL FUNCTIONS:

•  Compiles/Coordinates current enrollment material. 
  • Coordinates the completion of current enrollment materials, ensuring that the current versions of forms are being used.
  • Collaborate with other departments and practitioner offices to obtain materials needed for credentialing and enrollment as part of the credentialing process.
  • Coordinates receipt of credentialing/enrollment materials; Follows up on any missing items in a timely manner.
• Credentialing/Re-Credentialing and Enrollment Responsibilities.
  • Completes primary source verifications, to obtain required documents in accordance with the delegated credentialing agreements and NCQA standards. 
  • Maintains credentialing database and internal systems with new and existing practitioner data, interacts with external databases/systems to complete the credentialing/re-credentialing process.
  • Relays enrollment information to health plans in accordance with payor requirements in efficient and timely manner.
  • Performs re-credentialing function in a timely manner ensuring process occurs within the required three-year time frame, as determined by each practitioner’s previous credentialing or re-credentialing date.
• Understands, Communicates, Maintains and Tracks Credentialing related materials.
  • Demonstrates working knowledge and understanding of payor credentialing and enrollment, hospital membership/privileging, contracting, NCQA and delegation standards and medical terminology as it relates to credentialing and enrollment.
  • Generates and responds to correspondence and inquiries related to the credentialing and enrollment process, clarifying requirements and timelines, handle deadlines, multiple responsibilities and prioritize workload.
  • Maintains provider demographic updates including terminations and changes within credentialing database and externally to delegated payors.  
  • Tracks expirations of licenses, certifications, and liability coverage to ensure timely renewals. 
• Demonstrates commitment to professional growth and high standards of performance.
  • Establishes excellent rapport with the department staff, representatives from health plans, and practitioner office staff to enhance and promote the quality and value of the organization.
  • Contributes to team performance through collaboration on tasks, participation in team meetings, credentialing committee meetings and staff meetings.
  • Demonstrates effective time management and prioritization skills by setting deadlines and completing commitments within negotiated time frames.
  • Attends appropriate in-services/meetings to enhance the understanding of current healthcare environment.
  • Seeks formal and informal opportunities to expand knowledge and skills related to current and future performance requirements.
  • Maintains strict confidentiality of all issues and department information, according to established guidelines.
  • Assists the Credentialing Manager in other delegated tasks and duties as assigned.    

 Other Functions:

• Performs other duties as assigned.

 The duties listed above are intended only as illustrative of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar or a logical assignment to the position.

QUALIFICATIONS AND COMPETENCIES:

• Bachelor’s Degree and/or equivalent experience in related field.
• Certified Provider Credentialing Specialist (CPCS) OR Achievement of certification (CPMSM/CPCS) within 12 months of becoming eligible 
• At least three years in a managed care environment or equivalent.
• Understanding of all credentialing across all payer types – Commercial, Medicare, Medicare Advantage and Medicaid
• Knowledge and understanding of NCQA credentialing guidelines, ability to organize, prioritize and manage multiple priorities, utilize analytical skills with strong attention to detail, ability to research information, ability to problem solve, excellent communication both verbally and written, emails and memos; ability to establish and maintain professional and effective working relationships with practitioners and their office staff, the Medical Staff office as well as other internal and external contacts; proficiency in Microsoft Office applications and Internet resources; have a strong work ethic. 
• Knowledge of credentialing within an employed medical group preferred- to include practice, facility, and provider level (re)credentialing, licensure, and database management

 PHYSICAL AND MENTAL REQUIREMENTS:

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

• Frequently required to maintain a stationary position and move or traverse.
• Ability to transport and/or maneuver objects weighing up to 20 pounds.
• Vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  
• The dexterity necessary to utilize a computer keyboard regularly is essential
• Busy work environment subject to frequent interruptions and shifting potentially conflicting priorities.

 ADDITIONAL REQUIREMENTS:

• As a condition of employment at SoNE HEALTH, all employees must reside in New Hampshire, Rhode Island, Maine, Vermont, Connecticut, or Massachusetts.
• For the safety and well-being of our employees, all employees are required to be fully vaccinated for influenza.
• If you will be working in a remote or hybrid capacity, we require a stable internet connection. We recommend that you have an internet service provider with speeds of at least 30Mbps download/5Mbps upload. 

 ADHERENCE TO THE SoNE HEALTH CODE OF CONDUCT:

• Code of Conduct: Employee will understand and follow the guidelines and standards outlined in the SoNE HEALTH Code of Conduct and demonstrate an understanding of the SoNE HEALTH Mission, Vision and Core Values.
• Policies and Procedures: Employee will comply with all SoNE HEALTH policies and procedures relevant to their role, including those related to compliance, safety and confidentiality.
• Regulatory Requirements: Employee will ensure actions and behaviors are in accordance with applicable laws, regulations, professional standards, policies, procedures and the Code of Conduct.

BENEFITS:

We offer a competitive compensation package, which includes a comprehensive benefits program that begins on the first of the month following date of hire. 

Our benefits include:

• Medical, dental, and vision insurance
• 401(k) retirement plan with employer match
• Short-Term Disability Insurance
• Long-Term Disability Insurance
• Basic Life & Accident Insurance
• Flexible Spending Accounts
• Voluntary Benefits
  1. Homeowners Insurance
  2. Auto Insurance
  3. Critical Illness Insurance
  4. Pet Discount Plans
• Earned time off, sick time, company holidays and one floating holiday
• Paid Volunteer Time
• Employee Assistance Program
• Educational Assistance (Tuition Reimbursement) after one year of employment
• Employee Discount Program for discounts on entertainment, travel, and shopping