Job Description

Job Description

Job Description

Primary Purpose:
The Credentialing Specialist is responsible for credentialing and re-credentialing of practitioners as well as ensuring enrollment with participating client health plans. Credentialing functions include, but are not limited to, processing credentialing applications, performing primary source verifications and updating and maintaining credentialing database in accordance with internal policies and procedures, client health plan contracts, and state and federal requirements.

Essential Job Functions:
1.Conducts thorough background investigation, research and primary of components of the application file; completes provider credentialing and re-credentialing applications; monitors applications and follows- up as needed; and processes applications with respective agency and/or thirdparty payer to ensure compliance.

1. Performs credentialing of faculty and professional staff with Medicare, Medicaid, HMO, PPO's and other 3rd party carriers to ensure providers are contracted.

1. Maintains up-to-day data for each provider for each provider in databases and online systems as it relates to education, training, licensing and experience to ensure practice addresses are current with health plans, agencies and other entities.

1. Applies for Provider's Hospital Privileges; is responsible for hospitals reappointment's; also responsible for Medical Staff Due payments requests and payment processing to ensure timely and accurately

1. Assist in keeping current the Clinical Laboratory Improvement Amendments (CLIA) Certification for clinical operations.

1. Tracks license and certification expiration's for all providers to ensure timely renewal. Assures contacts and licenses do not expire, and submit new licensing information to appropriate contacted entities.

1. Maintains provider credential files in a secure manner and provide support for colleges review

1. Is responsible for keeping up to date on new policies and procedures from third party payers and communicates to appropriate staff. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing.

1. Assists with managed care delegated credentialing audits; conducts internal file audits, and audits health plan directories for current and accurate provider information.

1. Responds to inquiries from other health care organizations, interphases with internal and external customers on day-to-day credentialing and privileging issues.

1. Participates in contracting functions and is responsible for understanding contract

1. Performs other duties as assigned by

Required Knowledge, Skills, & Abilities:

1. Knowledge of related accreditation and certification

1. Ability to work independently and manage multiple projects efficiently and accurately; ability to adapt to change and meet deadlines.

1. Ability to research and analyze

1. Ability and commitment to excellent customer service to maintain and ensure effective working relationships with providers, staff, and contacts internally and externally.

1. Excellent attention to detail and high degree of

1. Ability to communicate effectively, both orally and in

1. Proficient use of MS Office applications (Word, Excel, and Outlook) and internet informational research

PHYSICAL REQUIREMENTS / WORKING CONDITIONS:

1. May be exposed to short, intermittent, and/or prolonged periods of sitting and/or standing in performance of job duties.

1. May be required to accomplish job duties using various types of equipment/supplies, to include but not limited to pens, pencils and computer keyboards.

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