Credentialing Specialist

Under the direct supervision of the Director of Human Resources, performs credentialing and recredentialing in accordance with NM Medicaid, Medicare PECOS, CAQH, and policy and procedure requirements. The Credentialing Specialist manages staff credentialing files working cooperatively with direct care paraprofessionals, practitioners, internal departments and contracted payors to ensure the seamless and timely flow of credentials information in order to meet credentialing deadlines. This individual must demonstrate initiative, resourcefulness and problem-solving skills in executing functions to ensure the orderly flow of business.

The credentialing specialist is responsible for reviewing and verifying the qualifications, licenses, certifications, liability coverage, and other relevant documents submitted by behavioral health providers to ensure they meet the necessary standards for practice within TeamBuilders, including data collection, application processing, and maintaining accurate credentialing records, all while adhering to compliance regulations. 

Duties and Responsibilities:

1. Supports direct care staff with credentialing/primary sourcing verification program by coordinating and developing internal processes in order to meet requirements of federal and state regulatory and national accreditation agencies.

2. Collects and reviews provider applications, licenses, board certifications, liability/ malpractice insurance information, and other required documentation. 

3. Accurately inputs provider data into EMR and payor online systems, maintains up-to-date records, and tracks/reports expiration dates of licenses and certifications as well as pursues updated licenses and certifications as needed. 

4. Monitors timeliness of processes and provides feedback and/or reports to the appropriate manager/director.

Audits accuracy of data entry in the credentialing databases (internal and external) and provides feedback to appropriate internal and external customers.

5. This position requires knowledge of medical and healthcare staff credentialing processes and requirements.

6. Investigates issues of concern and conducts follow-up as needed, generates reports and presents findings to executive management.

7. Investigates discrepancies in data submittal related to applications, credentialing statuses and privileges, and formulates appropriate course of action.

8. Provides excellent customer service by responding to provider, client, and customer inquiries within specified timeframes, as required by the department.

9. Ensuring that provider credentials meet all applicable state and federal regulations, as well as internal organization policies. 

10. Contacting licensing boards, and other relevant entities to verify the authenticity of provider credentials. 

11. Submitting provider credentialing applications/rosters to payers following their specific requirements and timelines. 

12. Track candidate background checks to ensure that candidate is eligible for hire. 

13. Completes employment verifications, and references checks for new hires. 

14. Contacting providers to request missing information, clarify details, and update credentialing status. 

15. Preparing reports regarding provider status and potential credentialing issues. 

16. Track provider credentialing expiration dates and initiating the re-credentialing process as needed.

17. Other duties may be assigned.

Minimum Qualifications:

1. High School Diploma or GED required; Bachelor's degree in Business Administration, Human Resources, or related field preferred.

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

3. Two years of demonstrated experience with credentialing (beyond summer or short- term internships). Equivalent combination of education and experience sufficient to successfully perform the essential job duties may be considered.

4. Obtain a Criminal Records Clearance (local, state, and FBI).

Required Skills 

A strong attention to detail is required for verifying complex credentialing information and ensuring compliance with regulation. 

Ability to prioritize tasks driven by business needs and insurance requirements.Strong analytical and problem-solving skills.

Ability to work independently and with minimal supervision.

A sense of discretion and a high degree of professionalism is required.

Demonstrated ability to work in a small team setting.

Flexibility to adjust and contribute to continually evolving work situations and changing priorities.

Excellent computer skills, including proficiency with MS Office applications and HR management platforms.

Proficiency with or the ability to quickly learn the organization's medical record system.

Proficiency with Google Suite, Adobe Acrobat, and Microsoft Office Suite.

Demonstrated ability to manage large volumes of data, track multiple applications, and prioritize tasks effectivelyDemonstrated ability to clearly communicate with providers, payers, and internal stakeholders to gather information and resolve issues.

Demonstrated ability to consistently establish positive relationships, and to work effectively and cooperatively with clients, colleagues, and coworkers.

Must be computer literate for use of computerized data systems, software applications, and reporting, etc. Must also have and maintain a clean driving record and active auto insurance coverage.

Demonstrates a highly professional and cooperative demeanor with supervisors and co- workers.Strong interpersonal, communication, facilitation, and presentation skills.

Proven ability to give, deny or ask for information in a tactful and friendly manner and discretion in giving information about plans and/or action to anyone is required.

Excellent organizational skills with demonstrated ability to execute projects on-time and on- budget.