Credentialing Specialist

COMMUNITY HEALTH OF SOUTH FLORIDA INC• Miami, FL, US, FL

65d•$23 - $30

About The Position

The Credentialing Specialist is responsible for credentialing and recredentialing all billable providers, specialties, and facilities. They will obtain access to the different MCO, Medicaid, and Medicare portals for credentialing. The purpose is to credential the providers in a timely manner to enable CHI to bill for services provided. This role will provide support to the Director of Managed Care.

Requirements

Five years of experience in a healthcare-related position and/or Associate's degree or equivalent from a two-year college or technical school or equivalent combined experience.
Must maintain current CPR certification from the American Heart Association.
Certified Professional Coder (CPC/CPCA) required.
Knowledge of PC usage, Windows and Microsoft Office Applications, Database software, spreadsheet software, word processing software.
Knowledge of healthcare and/or community health center industry and practices.
Knowledge of Managed Care Organizations and their different lines of business; Commercial, Medicaid, Medicare, Exchange, Healthy Kids, etc.
CMS (Medicaid and Medicare)
Clear understanding of credentialing process

Nice To Haves

Experience working in a health care organization preferred
Coding experience preferred

Responsibilities

Primarily responsible for leading, coordinating, monitoring, and maintaining the credentialing and recredentialing process
Primarily responsible for processing credentialing, re-credentialing and enrollment applications of healthcare providers and sites, enforces regulatory compliance and adheres to quality assurance standards.
Performs accurate and timely credentialing processes for all initial applications and reappointments
Maintains current knowledge and ensures compliance with all accreditation, regulatory, health plan standards, and CMS
Ensures all primary source verification is completed within the time-frame as allowed by regulatory and accreditation entities.
Proactively works with center designees to acquire necessary materials and information.
Processes all appropriate queries for licensure, or any appropriate regulatory credentialing requirements, and maintains documentation in the database
Collects and verifies sensitive provider data through confidential sources and maintains a credentialing database
Performs analysis and appropriate follow-up of all applications
Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up
Ensures proper escalation of any issues impacting the completion of the application(s) or concerns brought forth by center/stakeholder
Completes accurate and timely data entry into the database to ensure consistency and integrity of the data
Tracks license and certification expirations for all providers to ensure timely renewals.
Prepares files for presentation to leadership and the credentialing committee
Ensures timely and effective communication with centers and stakeholders on the progress of all applications, addresses any inquiries set forth
Provides monthly reports of the credentialing and enrollment status to centers on the status of all assigned providers
Assists with internal auditing functions and performs peer evaluations as assigned
Audits health plan directories for current and accurate provider information.
Supports credentialing committee meetings as needed
Subject Matter Expert on Delegated and 3rd Party Payers
Internal Team Resource for Special Projects and Assisting Team Members who need additional credentialing application help
Other duties as assigned