Credentialing Specialist

UHS•Reno, NV

18d

About The Position

Prominence Health is a value-based care organization that connects affiliated health systems and independent providers through trusted collaboration. It serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships, with a focus on improving health outcomes, controlling costs, and enhancing the patient experience. The Credentialing Specialist investigates and verifies the backgrounds and credentials of practitioners and facilities contracted to provide care to Health Plan members. The role evaluates initial and re-credentialing applications, directs and oversees primary source verification, resolves discrepancies, and accurately summarizes investigation results for the Medical Director and Plan Credentialing Committee. The specialist provides written follow-up regarding credentialing decisions as required and ensures credentialing processes comply with applicable state, federal, and national regulations, as well as NCQA and Medicare (CMS) accreditation standards.

Requirements

High school diploma or equivalent.
1–3 years of related experience.
One year of physician-office or related medical-care experience.
Strong verbal and written English communication skills for interacting with provider applicants, applicants’ staff, the Medical Director, the Credentialing Committee, and other departments.
High attention to detail, strong organizational and prioritization skills, and the ability to handle confidential responsibilities accurately and meet established timelines.
Excellent computer skills, including word processing, databases, spreadsheets, and graphics.
Well-developed professional written and oral interpersonal communication skills.
Strong organizational skills and the ability to prioritize multiple tasks and projects using established protocols and guidelines.
Strong customer service skills.
Motivated, flexible, and self-starting.
Assertiveness, creativity, and problem-solving skills.

Nice To Haves

Medical staff office experience preferred.
Credentialing experience strongly preferred.
Strong medical terminology recommended.

Responsibilities

Investigate the backgrounds and credentials of practitioners and facilities contracted to provide care to Health Plan members.
Evaluate the adequacy of information submitted by applicants for initial credentialing and re-credentialing.
Direct and oversee primary source verification of credentialing elements.
Ensure clarification of discrepancies discovered during the verification process.
Summarize and report investigation results to the Medical Director and Plan Credentialing Committee.
Provide written follow-up regarding credentialing determinations as required.
Ensure credentialing processes comply with State, Federal, and National regulatory requirements and NCQA and Medicare (CMS) accreditation standards.