Credentialing Specialist

Overview:

The Medical Staff Credentialing Specialist will organize, maintain and verify all aspects of the process, and maintain current files on practitioners. You will track the expiration of certifications to maintain up-to-date files, and assist health plan providers and customers with phone inquiries. Ensures currency and accuracy of all information, and is expected to be reliable, energetic and have excellent people skills. This position reports to the Director of Revenue Billing & Cycle - Finance.

Duties and Responsibilities:

· Prepare and maintain credentialing files and reports for all individual providers including maintenance of credentialing software, provider rosters, and spreadsheets to comply with group delegation requirements.

· Process and file applications with third-party payors according to each payors individual requirements and address/corrects discrepancies as requested by payors.

· Conduct all follow-up steps until payor approval/completion is obtained.

· File provider practice changes notifications and performs follow-up duties till confirmed complete by payors.

· Update NPI records according to provider specifications.

· Enroll provider in Medicare/Medicaid as prescribed by each program requirements.

· Track provider licensure and Board expirations, and ensures timely processing of CAQH, TMHP, and payor updates.

· Complete requests for re-credentialing for both providers and facilities.

· Accept and process all requests from payers for credentialing information/updates/new contracts and products

· Answer questions, process requests from staff/providers related to credentialing information.

· Ensure all records meet standards set by carriers as well as FQHC guidelines

· Enrolls facilities in Medicare/Medicaid programs.

· Address enrollment disconnects in regards to facility and providers

· Assist with EHRS enrollment, tracking, and filing

· Maintains quarterly payor specific rosters in accordance with CMS standards

· Assist in quarterly CAQH mass attestation

· Serves as liaison between Legacy and outside organizations and external customers.

· Participates in the Performance Improvement Program.

· Performs other duties as assigned.

Education, Experience, Licensure/Certification and Skills/Abilities Related Requirements:

· High School Diploma or GED

· Bachelor’s College Degree preferred

· At least five (5) years’ experience in capacity as credentialing coordinator or credentialing specialist

· Have good working knowledge of guidelines and requirements of agencies and carriers

· Must have strong, clear communication skills

· Detailed oriented and strong organizational skills required