Credentialing Specialist

Independent Health Association•Buffalo, NY

About The Position

The Credentialing Specialist is responsible for the timely and accurate credentialing and re-credentialing of all Independent Health providers. This role involves managing provider files and documentation in compliance with regulatory requirements and company policies. The specialist will collaborate with internal departments to ensure data accuracy and provide professional external customer service, utilizing the Healthrules system for all work.

Requirements

High School diploma or GED required
Two (2) years of healthcare operations experience required
Demonstrated experience in Windows and Microsoft Word
Excellent organizational and time management skills with ability to prioritize work according to established deadlines
Must be able to manage multiple projects
Ability to work independently owning a process from start to finish while under strict deadlines and decision-making skills commensurate with position responsibilities
Excellent written and verbal communication skills
Demonstrated ability to communicate with physicians and health care providers
Excellent customer service skills
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable

Nice To Haves

Associates Degree preferred
Credentialing experience preferred
Knowledge of HealthRules and Visual Cactus preferred

Responsibilities

Maintain the timely and accurate credentialing and re-credentialing of all Independent Health providers
Manage provider files and documentation in adherence with regulatory requirements and Independent Health policies
Work with internal departments to ensure the accuracy of the provider data
Provide effective, professional external customer service
Maintain all work through the Healthrules system
Input provider applications into credentialing database and process within required time frame
Ensure that all applications are complete and accurate and in compliance with NCQA, DOH, and CMS standards as well as Independent Health’s policy requirements
Complete and close clean, routine applications within required time frame
Initiate credentialing packets as assigned and scheduled
Perform tracking and process to maintain compliance with Federal, State, NCQA, and internal requirements
Initiate follow-up and action on any conflicting or incomplete information
Complete and close assigned recredential files with required time frame
Review and edit file for completeness and accuracy, meeting all regulatory requirements before turning in for analyst review
Maintain Network Evaluation process and profiles for physician network
Gather and document information from respective departments and ensure profiles are complete for recredentialing review
Perform primary source verification utilizing the credentialing software package according to IPA/WNY policies and procedures
Query primary sources by letter or phone for verification of provided information
Initiate additional request when response is not received within required time frames
Query data bases and utilize internet sources available for verification of license, board information, sanctions, and claims history
Maintain the credentialing data base and provider hard copy file
Enter all noted changes and update provider credentialing data base record, as applicable in both Cactus and Health Rules
Remain current and informed on credentialing policies and procedures
Generate routine reports as required from the system
Provide manager with status report of assigned files at month end
Generate reports required for follow-up as needed