GENERAL SUMMARY

The Credentialing Specialist is responsible and accountable for accurate and timely provider credentialing, to include new applicant credentialing, re-credentialing and ongoing maintenance of provider credentials and reports as required by commercial, federal and state payer and other regulatory (NCQA, URAC) or agency requirements. Performs a wide variety of administrative and support duties. Reports to department leadership.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Performs accurate and timely provider credentialing, to include new applicant credentialing, re-credentialing and ongoing maintenance of provider credentials and reports as required by commercial, federal and state payer, hospitals and other regulatory or agency requirements. Responsible for accurate and timely collection and data entry of CAQH, DEA, licensure and other provider enrollment requirements. Creates and facilitates completion of clinician applications for payer and facilities to ensure timely credentialing and enrollment. Prepares application packet to send out to providers. Assists in maintenance of listing of "pending applications." Receives application from potential applicant; review application for completeness/accuracy and initiate processing, including but not limited to (1) Primary source verification (educational, employment, licensure, insurance carriers and hospital affiliations). (2) OIG query. (3) Criminal Background Check submission. (4) Third party payers, CAQH and other related credentialing applications. Independently compiles and maintains organized computer files, paper files and data for immediate access and retrieval of materials. Maintains files according to established policy for record retention. Input data in various systems (credentialing software, hospital main-frame/Eclipsys, etc.). Maintains credentialing management documents, tracks credentialed providers for re-credentialing. Notifies risk management for certificate of insurance (COI). NPI number applications. Performs other duties as assigned.

LICENSES AND/OR CERTIFICATIONS

None required.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

High school graduate or GED. College degree preferred. Three years of experience in a related field required. Knowledge of medical terminology, computer skills and third party payer credentialing processes preferred. Ability to relate well with consumers, companies and multiple departments. Ability to effectively gather and exchange information in both oral and written communications and bookkeeping skills. Self-starter with ability to meet deadlines and maintain organized files.

WORKING CONDITIONS

Normal office environment with little exposure to excessive noise, dust, temperature and the like.

PHYSICAL REQUIREMENTS

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