JOB TITLE: Credentialing Specialist
FLSA STATUS: Non-Exempt
HOURS PER WEEK: 40
REPORTING RELATIONSHIP: Care Connections Coordinator
Under general supervision, coordinates and administers the credentialing process for licensed providers on behalf of a specified practice plan, or third party insurance payer organization, ensuring that all credentialing and accreditation processes and procedures are completed in accordance to established accreditation, regulatory, and policy requirements.
· Initiates and coordinates the acquisition and receipt of all credentialing documentation from new and existing providers; provides follow-up and problem resolution as required.
· Coordinates the processing, distribution, and management of all credentialing documents for providers.
· Requests, coordinates, records, and maintains background checks and license verifications in support of all credentialing applications.
· Develops and implements systems and procedures to ensure that all credentialing processes are completed in accordance with relevant regulations, policies and standards.
· Develops and maintains a comprehensive credentialing database and prepares reports and summaries as appropriate; monitors individual profiles.
· Maintains and ensures strict confidentiality of files and databases.
· Schedules, coordinates, and facilitates Credentialing Committee proceedings; provides follow-up and problem resolution regarding committee matters as appropriate.
· Acts as primary point of contact for all internal and external constituencies in all day-to-day administrative matters associated with the credentialing process.
· Troubleshoots and resolves problems and issues as they arise.
· Facilitates and assists with internal and external records audits as appropriate.
· Performs miscellaneous job-related duties as assigned.
REQUIRED KNOWLEDGE AND SKILLS:
· Basic computer knowledge.
· Knowledge of clinical provider credentialing principles, processes, procedures, and documentation.
· Ability to make administrative and procedural decisions and judgments on sensitive, confidential issues.
· Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
· Organizing and coordinating skills.
· Ability to develop and maintain filing systems.
· Skill in the configuration and use of computerized database programs.
· Recent experience as a Credentialing Coordinator.
· Ability to work cooperatively with providers.
· Ability to develop and maintain recordkeeping systems and procedures.
· Skill in the use of personal computers, online activities, and related software applications.
· Knowledge of provider credentialing regulations, policies, guidelines, and standards.
· High school diploma or GED with 5 to 7 years, experience directly related to the duties and responsibilities specified.
Associate’s or bachelor’s degree preferred or 5-7 years, equivalent experience
This job description in no way states or implies that these are the only job-related duties to be performed by the employee. He or she will be required to follow any other job- related instructions and perform any other job-related duties requested by his or her supervisor.