Credentialing Specialist

Summary:

The Credentialing Specialist is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing for all payors commercial and government related.

Essential Duties and Responsibilities:

• Initiate credentialing and re-credentialing applications for both individual providers and provider groups.
• Sets up/ maintains provider information in online enrollment databases, health plan and internal systems
• End-to-end credentialing process of all new and current providers, and with all contracted Insurance companies in multiple states.
• Oversee the screening of practitioners' applications and supporting documentation to ascertain their eligibility.
• Maintains confidentiality of provider and payer information
• Manage, negotiate , and renegotiate fee schedules to obtain the most optimal rates.
• Maintain individual provider files to include up-to-date information needed to complete the required governmental and commercial payer and credentialing applications.
• Maintain internal provider tracking database to ensure all information is accurate and logins are available.
• Update each provider's CAQH database file timely according to the schedule published by CMS
• Apply for and renew prior to expiration all provider licenses: professional state, DEA, and controlled substance registration.
• Complete revalidation requests issued by government payers.
• Complete credentialing applications to add providers to commercial payers Medicare, and Tricare.
• Review weekly new hires and termination report to update in credentialing database.
• Respond to health plan provider inquiries.
• Oversee and maintain the licensing/credential database.
• Perform and collect documentation for licensing, board certifications, proof of professional liability insurance.
• Ensure credentialing database contains up-to-date information at all times.
• Responsible for monitoring credentialing/re-credentialing requirements, as well as required certifications, and to ensure the collection of all required renewal certifications are on file within the required time frame.
• Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
• Work closely with leadership to track and oversee Collaborative Agreements between Nurse Practitioners and Physicians.
• Ensure compliance with applicable laws, regulations, procedures, and policies.
• Maintain working knowledge of the National Committee on Quality Assurance (NCQA) standards and State and Federal regulations related to credentialing

Required Education and Experience:

• Bachelor's degree in Healthcare or Business Administration/related field or 5 years of relevant experience. 
• 3 years of credentialing experience with hospital or physician practice medical staff.
• Experience with submitting applications for State, Federal, and Health Plan credentials.
• Experience with submitting applications for State, Federal, and Health Plan contracts.
• Experience with CAQH (Council for Affordable Quality Healthcare) database and application process.
• Knowledge of credentialing and procedures and standards.
• Excellent verbal and written communication skills.
• Proficient touch-typing skills.
• Ability to focus for extended periods.

Preferred Education and Experience:

• NAMSS Certification as a Certified Professional Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) is preferred.
• Working knowledge of credentialing accreditation regulations, policies, and procedures, and NCQA standards essential.
• Experience with submitting and maintaining Collaborative Agreements between Nurse Practitioners and Physicians.

Knowledge, Skills, and Abilities:

• Ensures work product demonstrates attention to detail, accuracy and completeness.
• The ability to multitask is essential.
• Incredibly organized and meticulous attention to detail is a must.
• Critical thinking skills to identify opportunities and make informed decisions.
• The ability to track details, deadlines, and priorities to ensure no details or deadlines are missed.
• Self-starter who will take initiative and be proactive when there are multiple priorities.
• Ensures Ethical Conduct in all areas of work performance.
• Communicates with co-workers, management, vendors and others in a courteous and professional manner.
• Team player with excellent interpersonal skills.
• Strong written and verbal communication skills.
• Conform with and abide by all regulations, policies, work procedures and instructions.