Credentialing Specialist - Professional

Curana Health, Inc.

About The Position

Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults by providing value-based care solutions to senior living communities and skilled nursing facilities. As a national leader, the company offers on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans, serving over 200,000 seniors in 1,500+ communities across 32 states. The team comprises more than 1,000 clinicians and various professionals working to deliver high-quality, proactive solutions. The Credentialing Specialist is responsible for all functions related to the credentialing and recredentialing of practitioner applicants, ensuring the provider network meets regulatory criteria to minimize company liability and maximize member safety.

Requirements

High school diploma required
1-4 years of hospital or insurance plan credentialing experience
Working knowledge of Joint Commission, NCQA, URAC, HFAP standards

Nice To Haves

Associate degree preferred
Certified Provider Credentialing Specialist (CPCS) preferred

Responsibilities

Maintain confidentiality regarding legal matters, privacy issues, information technology and data integrity
Perform detailed and thorough review of applications for completeness
Conducts, maintains, and analyzes Primary Source Verifications (PSV) as outlined in the organization policies while meeting production goals
Recognize potential discrepancies and adverse information, and independently investigate and validate information from applications, primary source verifications, or other sources
Communicates with health care practitioners to clarify questions and request any missing information
Conducts follow-up on application requests and outstanding PSVs, following department guidelines and production goals
Maintains credentialing software database by ensuring that data entered is complete and accurate
Communicates with internal and external customers in a clear, concise manner to obtain or provide necessary information
Compile, evaluate, and present the practitioner-specific data collected for review by the Credentials Committee
Creates and sends formal approval, requests for information and termination notices to practitioners based on Credentials Committee decisions
Requests recredentialing applications from practitioners and organizational providers
Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants
Conducts ongoing monitoring of provider expirables such as license, DEA and malpractice insurance
Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if practitioners have sanctions/exclusions
Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found
Assists with Delegation Oversight audit reviews, tracking and reporting.