Credentialing Specialist
About The Position
The Credentialing Specialist ensures that Point32Health-affiliated physicians, independent practitioners, and allied providers are qualified to provide healthcare services to members in accordance with organizational policies and procedures, state laws, and regulatory requirements such as NCQA. Practitioners are recredentialed at least every three years, or more frequently when required. The role maintains and processes credentialing information for new and established health plan practitioners. It assesses the accuracy and adequacy of participation information, enters applications into the Cactus credentialing information system, verifies licenses and board certifications, reviews adverse information, and obtains missing or expired documentation. The specialist also responds to provider questions and escalates complex or sensitive matters to the Credentialing Supervisor or appropriate reviewers. The position prepares files for daily review by credentialing staff and Medical Directors, including files that meet credentialing criteria and files that may not meet criteria and may require presentation to the Quality-of-Care Committee. It processes practitioners under the terms of applicable entity agreements, including files credentialed through a Certified Verification Organization, and participates in assigned task forces and meetings. The role requires working under normal office conditions and from home as required.
Requirements
- High school diploma.
- One to two years of experience in the healthcare field.
- Experience with a personal computer.
- Ability to appropriately identify emergency situations and follow the appropriate protocol.
- Ability to maintain and manipulate a complex credentialing information system.
- Ability to prioritize multiple tasks and meet deadlines.
- Ability to adapt to a changing environment.
- Strong written and verbal communication skills.
- Initiative, sound judgment, exceptional organizational skills, and keen attention to detail.
- Ability to work with and process time-sensitive information.
Nice To Haves
- Bachelor’s degree.
- Experience with provider credentialing.
- Knowledge of Word and Excel.
Responsibilities
- Maintain and process credentialing information for new and established health plan practitioners in accordance with organizational policies, state laws, and regulatory requirements.
- Assess whether information submitted for participation is adequate and accurate, including limited knowledge of provider contract information.
- Enter initial and existing credentialing applications accurately and promptly into the Cactus credentialing information system.
- Verify practitioner licenses, board certifications, and other required credentials through appropriate sources.
- Review and report adverse information from the National Practitioner Data Bank and state and federal sanctions.
- Retrieve missing or expired information and documentation required for credentialing.
- Answer physician and provider questions about certification and the credentialing process.
- Identify issues of broader complexity or sensitivity for the Credentialing Supervisor and escalate them for further action as appropriate.
- Prepare files that meet credentialing criteria for review by the Credentialing Compliance Coordinator and/or Supervisor and presentation to the daily Medical Director file review.
- Prepare files that may not meet credentialing criteria for review by Medical Directors, a Senior Credentialing Specialist, and/or Supervisor, and for presentation to the Quality-of-Care Committee, including reporting adverse information.
- Process practitioners daily under applicable entity agreement terms and conditions, including files credentialed through a Certified Verification Organization.
- Participate in assigned task forces and meetings and perform other assigned responsibilities, duties, and projects.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance, with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Benefits supporting career development, individual and family health, and financial health
- Eligibility for variable pay
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
