Credentialing Specialist- Healthcare

Concentra•Addison, TX

14h

About The Position

Concentra is recognized as the nation’s leading occupational health care company.With more than 40 years of experience, Concentra is dedicated to our mission to improve the health of America’s workforce, one patient at a time. With a wide range of services and proactive approaches to care, Concentra colleagues provide exceptional service to employers and exceptional care to their employees. Credentialing Specialist performs all functions in support of onboarding to include initial credentialing, recredentialing, and credentialing monitoring requirements including, but not limited to, performing a comprehensive quality review of “non- standard” credentialing/re-credentialing, which includes those files with questionable clinical, quality and/or business issues, provider license monitoring, updates to credentialing database from internal reports and notifications, and initiation of CAQH application process for initial credentialing, initiation of recredentialing process. Additionally, this position is responsible forassisting with the routing of files to and from the medical advisor and to and from the credentialing committee.

Requirements

Education Level: High School Diploma or GEDDegree must be from an accredited college or university.
Minimum 1-2 years direct experience in credentialing required - CAQH experience preferred
Knowledge of credentialing software (IntelliCred) is preferred
Working knowledge of NCQA, URAC and/or AAHC credentialing standards
Concentra Core Competencies of Service Mentality, Attention to Detail, Sense of Urgency, Initiative and Flexibility
Ability to make decisions or solve problems by using logic to identify key facts, explore alternatives, and propose quality solutions
Outstanding customer service skills as well as the ability to deal with people in a manner which shows tact and professionalism
The ability to properly handle sensitive and confidential information (including HIPAA and PHI) in accordance with federal and state laws and company policies
Ability to work independently within guidelines and company policies.
Working knowledge of credentialing applications, processes, procedures and systems.
Working knowledge of computer software applications such as word, access database and spreadsheets.
Ability to effectively present information and respond to questions from managers, clients, and internal and external customers.
Ability to work in fast paced environment with short or time sensitive deadlines.

Nice To Haves

Certified Professional Credentialing Specialist (preferred)
Certified Professional Credentialing Specialist certification preferred

Responsibilities

Distribute packets for CAQH data, payer documents and MARs packet to new hires
Primary Source Verification of initial credentialing/re-credentialing files according to NCQA Standards
Appropriately identify and forward applicant initial and re-cred files which do not meet “standard” requirements to medical advisor and/or credentialing committee, according to established guidelines. Notify timely if any issues are identified and determine next course of action.
Enter and maintain clinician demographic and credentialing information in credentialing database (IntelliCred) obtained through credentialing application, primary source verifications, internal reports, and notifications
Facilitate creation and/or updating of CAQH applications for initial credentialing and recredentialing when clinician is onboarding through new hire process or new business development process.
Participate in credentialing committee meetings to assure committee members have necessary information, explain questionable information contained in file and act as overall resource for general credentialing processes
Conduct license monitoring process for all providers in accordance with licenses, certificate and boards monitoring policy, to include initiation of letters, reports, and primary source verification of renewals
Identify issues in clinician's file that require committee review - create a medical review file and
Obtain all requested data elements per committee chairman's request for file to be completed to present to committee.
Works with External Payer Credentialing and Medicare Enrollment teams on various credentialing projects and internal interfacing processes.
Submit information required to risk department to obtain COI prior to start date and in order to complete file with high quality work in a quick and efficient turnaround time.
Collaborate with recruiting, onboarding, risk management and hiring manager to complete prehire clearance and credentialing process for start date to be confirmed