Senior Credentialing Specialist

DRISCOLL HEALTH PLAN•Corpus Christi, TX

About The Position

Where compassion meets innovation and technology and our employees are family. Thank you for your interest in joining our team! Please review the job information below. ESSENTIAL DUTIES AND RESPONSIBILITIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration as required. Always maintains utmost level of confidentiality. Adheres to DHS/DHP policies and procedures. Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. Performs day-to-day activities related to maintaining the credentialing and recredentialing of all providers and provider type of files. Update and maintain accurate provider demographic information in credentialing database to ensure consistency of all provider data. Request and maintain updated credentialing documents from providers on an ongoing/as needed basis and prior to any expirations to ensure there is no lapse in coverage or provider status and any random deliveries of documents (CLIA, MD Licenses, Malpractice Ins, etc.) Run regularly scheduled reports to identify and address any outstanding applications, issues, and expiring information. Serves as a subject matter expert and provides escalation support for outstanding credentialing issues. Assist the Supervisor and Manager in development, implementation and maintenance of processes that support department and organization goals. Writing out workflows and processes of files. Assists in quality review for Committee accreditation audits, Recredential report of floater files, Provider audit reports, SIU request of files. Assists with preparing Credentialing Committee meeting agendas, taking minutes, and communications with Credentialing Committee members as needed. In collaboration with the Supervisor/Manager, will lead credentialing special projects, reporting, quality review and metrics. Monitor and review the quality report for rejects on the roster Sandy Sosa produces. Assists with the training and ongoing development of Credentialing Specialist. Performs other duties as assigned to facilitate departmental and organizational goals. EDUCATION AND/OR EXPERIENCE: High school diploma or general education degree (GED). —Associate degree (A. A.) in a related field or equivalent from two-year college preferred. A minimum of 4 years’ experience in health plan credentialing. Knowledge of provider credentialing procedures and standards. Experience with Microsoft Word and Excel. Until all children are well. Driscoll Children’s Hospital and its specialty centers, urgent care centers, and after-hours facility serve a vast area covering 31 South Texas counties. The hospital is a 191-bed tertiary care center offering 32 medical and 13 surgical specialties. Combined with our non-profit, community-based Health Plan, Driscoll Health System is an exceptional workplace for anyone with a big heart and a drive for success. Smiles, hugs and a soothing touch are as much a part of Driscoll’s approach to treating children as is its advanced medical treatments and technologies. The core values at Driscoll Heath System are: Compassion, Advocacy, Respect, Excellence, and Stewardship. These values are exemplified through every position - from treating the most critical patients hands-on, to maintaining a clean environment, to keeping the organization running from behind the scenes. We invite you to learn about Driscoll’s rich history and explore the laidback lifestyle South Texas has to offer.

Requirements

High school diploma or general education degree (GED).
A minimum of 4 years’ experience in health plan credentialing.
Knowledge of provider credentialing procedures and standards.
Experience with Microsoft Word and Excel.

Nice To Haves

Associate degree (A. A.) in a related field or equivalent from two-year college preferred.

Responsibilities

Always maintains utmost level of confidentiality.
Adheres to DHS/DHP policies and procedures.
Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
Performs day-to-day activities related to maintaining the credentialing and recredentialing of all providers and provider type of files.
Update and maintain accurate provider demographic information in credentialing database to ensure consistency of all provider data.
Request and maintain updated credentialing documents from providers on an ongoing/as needed basis and prior to any expirations to ensure there is no lapse in coverage or provider status and any random deliveries of documents (CLIA, MD Licenses, Malpractice Ins, etc.)
Run regularly scheduled reports to identify and address any outstanding applications, issues, and expiring information.
Serves as a subject matter expert and provides escalation support for outstanding credentialing issues.
Assist the Supervisor and Manager in development, implementation and maintenance of processes that support department and organization goals.
Writing out workflows and processes of files.
Assists in quality review for Committee accreditation audits, Recredential report of floater files, Provider audit reports, SIU request of files.
Assists with preparing Credentialing Committee meeting agendas, taking minutes, and communications with Credentialing Committee members as needed.
In collaboration with the Supervisor/Manager, will lead credentialing special projects, reporting, quality review and metrics.
Monitor and review the quality report for rejects on the roster Sandy Sosa produces.
Assists with the training and ongoing development of Credentialing Specialist.
Performs other duties as assigned to facilitate departmental and organizational goals.