Credentialing Specialist

Manages departmental activities to ensure quality in conducting, maintaining and communicating practitioner credentialing and provider enrollment.  Serves as a resource to departments and management staff of each practice location to advance the quality of practitioners, increase patient safety of the clinic and improve quality of patient care to the practice.

Essential Position Functions:

• Data Management and Presentation:
  • Compile, evaluate, and present practitioner-specific data for credentialing committee reviews.
• Application Analysis:
  • Analyze applications and supporting documents for accuracy and completeness.
  • Ensure timely verification of credentialing and recredentialing applications through systematic follow-ups and inquiries.
• Discrepancy Investigation:
  • Identify, investigate, and validate any discrepancies or adverse information from applications and primary source verifications.
• Database Maintenance:
  • Maintain an up-to-date credentialing database, ensuring accurate information is accessible for practitioners, management, departments, and online profiles.
• Regulatory Compliance:
  • Assist in compliance with accrediting and regulatory agencies (e.g., Dental boards, NPDB, NCQA, CMS).
  • Develop and maintain a working knowledge of relevant statutes and laws.
• Reporting and Documentation:
  • Coordinate and prepare reports on credentialing and payor enrollment processes.
  • Develop and update policies and procedures to ensure compliance with organizational practices.
  • Manage forms and letters for new employee orientation, credentialing, and provider enrollment.
• Adverse Action Reporting:
  • Identify and report adverse actions against practitioners/providers as per legal and contractual requirements.
• Monitoring and Auditing:
  • Monitor and report expirables, recommending actions to management.
  • Participate in audits of delegated credentialing entities.
• System Utilization:
  • Audit, assess, and effectively utilize credentialing processes and information systems.
  • Implement and maintain e-files, reports, and databases based on the practice's credentialing needs.
• Practitioner Support:
  • Notify and reimburse practitioners for expirables.
  • Support practitioners through the payor enrollment process.
  • Participate in onboarding/orientation, educating practitioners on credentialing and enrollment processes.
  • Provide training and back-up support to practice managers and practitioners regarding work scope and credentialing.

Associates Degree in Business Administration or a related field and 3 years’ experience performing similar work or an equivalent combination of education or experience which leads to the ability to perform the essential functions of the position.

Licenses, Certifications and Registrations

Certified Provider Credentialing Specialist (CPCS) preferred.

Knowledge of:

• National credentialing standards such as NCQA and CMS.
• Medical and dental terminology.
• Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Federal and state regulatory agency requirements and standards.
• Employment law (NPDB, FCRA, Civil Rights, ADA, EEOC)

Skills:

• Credentialing software, human resources information systems (HRIS), electronic health records (EHR) Microsoft Office, state and federal software programs and Adobe Professional.
• Facilitates positive, professional and constructive dialogue with the goal of motivating others to accept recommendations, cooperate, change behavior or find mutually acceptable solutions.
• Expresses thoughts clearly, concisely and effectively both verbally and in writing. Ensures a free flow of information and communication upward, downward and across the organization by actively listening and encouraging the open expression of ideas and opinions.
• Organizes work, effectively prioritizes and sets short- or long-term goals and strategies to achieve them. Aligns communication, people, processes and resources to drive success.
• Organizes information and data to identify/explain trends, problems and their causes. Compares, contrasts and combines information to determine underlying issues. Sees association between seemingly independent problems or events to recognize trends, problems and possible cause-effect relationships.

Ability to:

• Communicate and analyze data and information.
• Maintain confidentiality of information regarding credentialing matters and other sensitive personal/professional information.
• Display a credible presence and positive image. Develops other people’s confidence in self through consistent action, values and communication.
• Transfer software skills to new software programs.

We provide:

• A stable, dentist-owned private company with an eye on the future.
• Excellent benefits including:
  • Paid time off
  • 401k $1 for $1 match up to 5% of your compensation or the IRS limit for 401(k) contributions, whichever comes first
  • Medical, dental, life and disability insurances
  • Tuition reimbursement
• A culture of inclusivity and respect in line with our core values of health, compassion, innovation and integrity.
• Supportive community outreach dollars and encouragement to volunteer.
• Thorough employee orientation and onboarding.

We are:

• A provider and employer of choice in the Northwest for 50 years.
• Dental insurance providers in over 50 general and specialty offices in OR, WA and ID.
• Dedicated to proactive care to facilitate the best possible outcomes.

We evaluate qualified candidates without regard to race, color, religion, sex, national origin, veteran status and other protected characteristics.

This job description is not meant to be an all-inclusive list of duties and responsibilities, but constitutes a general definition of the position’s scope and function in the company.

This position may be exposed to PHI in the course of his/her duties, and will handle protected information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Salary : $401,000