Credentialing Specialist (Provider)

Qualified candidates must have the following: 

**Credentialing requirements for insurances

** Knowledge of CAQH profile and attestation

**Application process and verification of Medicare and Medicaid

** Hospital Privileges application process

**Medical /Commercial Insurance application process

1. Conducts thorough background investigation, research and primary of components of the application file; completes provider credentialing and re-credentialing applications; monitors applications and follow up as needed; and processes applications with respective agency and/or third party payer to ensure compliance.

2. Performs credentialing of faculty and professional staff with Medicare, Medicaid, HMO, PPO's and other 3rd party carriers to ensure providers are contracted.

3. Maintains up-to-day data for each provider for each provider in databases and online systems as it relates to education, training, licensing and experience to ensure practice addresses are current with health plans, agencies and other entities.

4. Applies for Provider's Hospital Privileges; is responsible for hospitals reappointment's; also responsible for Medical Staff Due payments requests and payment processing to ensure timely and accurately treatment.

5. Assist in keeping current the Clinical Laboratory Improvement Amendments (CLIA) Certification for clinical operations.

6. Tracks license and certification expiration's for all providers to ensure timely renewal. Assures contacts and licenses do not expire, and submit new licensing information to appropriate contacted entities.

7. Maintains provider credential files in a secure manner and provide support for colleges review committees.

8. Is responsible for keeping up to date on new policies and procedures from third party payers and communicates to appropriate staff. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing.

9. Assists with managed care delegated credentialing audits; conducts internal file audits, and audits health plan directories for current and accurate provider information.

10. Responds to inquiries from other health care organizations, interphases with internal and external customers on day-to-day credentialing and privileging issues.

11. Participates in contracting functions and is responsible for understanding contract terms.

12. Performs other duties as assigned by supervisor.

Marginal Job Functions: Required Knowledge, Skills, & Abilities:

1. Knowledge and understanding of credentialing process.

2. Knowledge of related accreditation and certification requirements.

3. Ability to work independently and manage multiple projects efficiently and accurately; ability to adapt to change and meet deadlines.

4. Ability to research and analyze data.

5. Ability and commitment to excellent customer service to maintain and ensure effective working relationships with providers, staff, and contacts internally and externally.

6. Excellent attention to detail and high degree of accuracy.

7. Ability to communicate effectively, both orally and in writing.

8. Proficient use of MS Office applications (Word, Excel, and Outlook) and internet informational research skills. PHYSICAL