Senior Credentialing Specialist, TPR
About The Position
The Senior Credentialing Specialist, TPR, will work closely with the local market onboarding team on all new providers in the pipeline. This role involves requesting credentialing data and supporting documents from physicians, and communicating any delays that may jeopardize project timelines. The specialist will prepare and/or update provider CAQH applications, build and maintain peer-to-peer relationships with health plans, and strategically communicate newly affiliated providers to initiate TIN changes or credentialing. A key aspect of this role is establishing credentialed status to facilitate billing and maintaining credentialing databases with up-to-date tracking of file processes. The specialist will demonstrate in-depth knowledge of standard operating procedures (SOPs), communicate issues, trends, and concerns to the Regional Supervisor, and possess a working knowledge of various plan applications and workflow processes. Identifying opportunities for process improvement and challenging payor agendas with the Regional Supervisor are also important. Ensuring all workflow items are completed within set turn-around-times and meeting quality expectations is crucial. This role also involves issue resolution related to billing and collecting for services rendered, and educating internal markets on contractual obligations for each payor regarding authorizations, billing requirements, and operationalizing language to ensure timely billing and collection.
Requirements
- Minimum of five years of experience in a managed care role, centralized credentialing office or related health care environment, such as credentialing or file maintenance.
- Knowledge of health plan and governmental payer credentialing, enrollment, and requirements.
- Knowledge of CAQH application.
- Knowledge of contract language interpretation and administration.
- Ability to work within a deadline-intense environment.
- Demonstrated problem-solving and customer service skills.
- Knowledge of Microsoft Word and other PC applications.
- High School Diploma required.
- Excellent verbal and written communication skills.
Nice To Haves
- completion of an applicable Vocational or Technical training program preferred.
Responsibilities
- Data Entry - 5%
- Initial credentialing or recredentialing per NCQA - 30%
- Health plan submission (delegated, non-delegated) - 30%
- UCC credentialing - 25%
- Other duties as assigned - 10%
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
