Provider Credentialing Specialist (Org Wide)

Lakeland Care • Fond du Lac, WI

14h

About The Position

The Provider Credentialing Specialist develops and maintains a network of high-quality, culturally competent service providers to meet members’ needs. The role establishes service provider contracts and ensures contracted providers comply with regulations applicable to their services. It monitors provider credentials and licenses, negotiates rates, finalizes contracts, and supports compliance with Lakeland Care’s provider selection and retention policies. The specialist also creates, develops, monitors, and maintains electronic provider records to substantiate credentialing and contract compliance.

Lakeland Care is a Wisconsin-based nonprofit managed care organization that provides long-term care services and supports through Wisconsin’s Family Care program to eligible frail elders and individuals with physical, intellectual, or developmental disabilities. It serves 22 counties and operates 10 offices in Wisconsin’s Central to North East region.

Requirements

• Bachelor’s degree in a human service or business-related field, or an equivalent combination of education and experience, including relevant knowledge, skills, and abilities.
• Exceptional organizational skills, accuracy, and precision in record-keeping activities.
• Strong communication skills, determination, and ability to motivate others.
• Current driver’s license, acceptable driving record, and proof of adequate insurance.

Nice To Haves

• Experience working with populations served by the Family Care program.
• Experience in provider credentialing in a health insurance and/or managed care environment.
• Knowledge of the health care or long-term care service provider industry, subcontracting, and licensing and regulatory systems.
• Knowledge of network provider contracting in a managed long-term care model.

Responsibilities

• Complete credentialing and re-credentialing applications, following up with providers to obtain all required documentation.
• Compile and maintain current, accurate data for current and incoming providers.
• Collaborate with providers during Lakeland Care’s Contracting and Certification processes.
• Negotiate provider reimbursement in accordance with Lakeland Care rate bands.
• Monitor renewal timelines for required documents and work with contracted providers to prevent lapses in compliance or eligibility to provide services.
• Support providers with basic questions about understanding and interpreting Lakeland Care service provider contract terms.
• Educate contracted providers about the Family Care program and state statutes.
• Participate in the External Quality Review (EQR) process.

What This Job Offers

• Job Type: Full-time