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Medical Insurance Credentialing Specialist
Job
Chesapeake Health Care
Salisbury, MD (In Person)
$47,840 Salary, Full-Time
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Job Description
POSITION SUMMARY
The Insurance Credentialing Specialist is primarily responsible for credentialing and recredentialing CHC practitioners with participating client health plans. Credentialing functions include, but are not limited to, processing and tracking the status of credentialing applications and updating and maintaining the credentialing database in accordance with internal policies and procedures, client health plan contracts, Joint Commission guidelines as well as applicable state and federal requirements. This position reports to the Chief Medical Officer.PRIMARY ACCOUNTABILITIES
Achieve Results Completes all aspects of provider insurance company credentialing ensuring process is completed in a timely and efficient manner for the billing process to occur. Operational Excellence Keep in contact with insurance companies to detect any problems that could delay the provider from getting credentialed in a timely manner. Relationships Possess a positive relationship among all staff within the organization. Possess a positive working relationship with other related business entities. Leadership & Stewardship Ensure all actions, job performance, personal conduct and communications represent the organization in a highly professional manner at all times.PRIMARY TASKS AND DUTIES
Ensure timely and accurate credentialing and recredentialing application submissions for each practitioner as it relates to the individual client health plans; monitor and report credentialing progress of each practitioner. Maintain timely and accurate data entry. Periodically revise practitioner data in the credentialing database; maintain paper and electronic data files for all practitioner's; use the Council for Affordable Quality Healthcare (CAQH) system to submit practitioner data as required by some client health plans to credential & recredential individual practitioners. Respond to all practitioner, client health plan, and internal inquiries in a timely manner. Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners for reimbursement with client health plan. Utilize extensive internet and telephone communications to obtain critical pertinent information. Keep Manager informed of potential credentialing or enrollment issues. All other duties as assigned.ESSENTIAL FUNCTIONS/KEY COMPETENCIES
Demonstrates knowledge of NCQA, Joint Commission, and HIPAA standards and how to apply Ability to communicate and interact with others effectively Ability to organize, manage and control work flow to meet deadlinesPOSITION REQUIREMENTS
Education- High school diploma or GED
- Bachelors degree or related field preferred but not required Experience
- Experience with medical and professional credentialing processes, policies and procedures, including delegated credentialing requirements.
- Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment.
- Minimum one year hands-on credentialing experience in a health care setting to include familiarity with practitioner enrollment, credentialing or network services experience is preferred.
- Experience with MS Office; especially Excel and Access.
- Knowledge with National Committee for Quality Assurance, URAC and/or The Joint Commission guidelines and standards related to credentialing is a plus.