Credentialing Specialist

Solis Health Plans

7h•Onsite

About The Position

The Credentialing Specialist is responsible for credentialing and re-credentialing activities of health care providers and facilities to ensure compliance with appropriate accrediting and regulatory agencies. Responsible for maintaining data integrity of credentialing database.

Requirements

At least one (1) year experience with credentialing in a health plan setting with Medicare/Medicaid experience preferred but not required
Provider network management or provider relations experience a plus
Knowledge of CMS/Medicare/Medicaid and NCQA credentialing requirements
Excellent customer service skills required
Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
Ability to work effectively independently and in a team environment
Ability to read, analyze, and interpret technical procedures or governmental regulations
Ability to write reports, business correspondence, and procedure manuals
Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
Ability to define problems, collect data, establish facts, and draw valid conclusions
Strong decision-making, analytical skills
Must be self-motivated, organized and have excellent prioritization skills
Must be able to work well under stressful conditions
Must be able to work in a fast-paced environment
Fluency in Spanish and English required

Nice To Haves

Medicare/Medicaid experience preferred but not required
Provider network management or provider relations experience a plus

Responsibilities

Screening practitioner and facility applications and supporting documentation to ensure compliance with minimum credentialing criteria
Process practitioner and facility initial and re-credentialing activities in compliance with NCQA, state, and/or federal regulations and requirements, as applicable
Maintain excellent communications and strictly adheres to department processes between credentialing, provider relations and contracting
Maintains Credentialing database to ensure data accuracy
Ensure provider credentialing and re-credentialing is conducted in accordance with organizational policies and applicable government and regulatory agency standards and guidelines.
Maintains credential reports.
Prepares agenda, documents, and minutes for the Credentialing Committee
Ability to perform monthly monitoring of NPBD and oversee sanctions process including but not limited to streamline verify
Effectively improve operational processes to achieve maximum efficiency.
Assists in the review of Credentialing policies and procedures.
Maintains confidentiality of all information in compliance with State and Federal law.
Communicate effectively with other professionals to achieve positive customer outcomes.
Promotes and contributes to a positive, problem-solving environment.
Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations.
Participate in meetings, training and in-service education, as required.
Performs other duties as assigned.