Credentialing Specialist

JOB DESCRIPTION OVERVIEW:

• Position Summary:

Responsible for all aspects of the credentialing, recredentialing and revalidation processes for all medical providers who provide patient care for Rural Health Services, Inc. Responsible for ensuring providers are credentialed and revalidated with health plans, hospitals, and other patient care facilities as needed. Maintain up-to-date data for each provider in credentialing databases and online systems.

• Essential Functions/Responsibilities:

• Maintain Compliance with all regulatory and accrediting institutions.

• Compiles and maintains current and accurate data for all providers for credentialing purposes.

• Conducts primary source verification, collects, and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards.

• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact the ability to enroll practitioners with payers.

• Completes provider credentialing and recredentialing applications with payors; monitors applications and follows-up as needed.

• Maintains knowledge of current health plans and agency requirements for credentialing providers.

• Sets up and maintains provider information in online credentialing databases and system (CAQH).

• Ensures practice addresses are current with health plans, agencies and other entities.

• Audits health plan directories, provider files, and processes to ensure accuracy and compliance.

• Provide credentialing updates at Administrative Staff Meetings and maintain up-to-date information on a spreadsheet that is readily accessible to Supervisor.

• Communicates frequently with providers, insurance companies, and other relevant parties regarding credentialing processes and requirements.

• Additional Responsibilities:

• Maintains confidentiality of provider information.

• Credentials and enrolls new facilities with payors.

• Assist billing staff with claims denied due to credential errors.

• Process and maintain privileging forms and letters for clinical staff for CMO/CEO approval.

• Process and submit enrollment applications to all payors.

• Maintains recredentialing with all payors.

• Manage all insurance databases to ensure all data is up to date.

• Performs other duties as assigned.

• Skills:

• Knowledge and understanding of the credentialing process.

• Ability to organize and prioritize work and manage multiple priorities.

• Ability to respond to emails timely and effectively.

• Excellent verbal and written communication skills including letters, memos, and emails.

• Excellent attention to detail.

• Ability to research and analyze data.

• Ability to work independently with minimal supervision.

• Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.

• Proficient use of Microsoft Office applications (Word, Excel, Access) and internet resources.

• Ability to function in a customer focused environment.

• Education Required:

• High school diploma or equivalent.

• Associate degree preferred.

• Experience: Two years of relevant credentialing experience

• Education Preferred:

• Certification/Licensure: Certified Provider Credentialing Specialist (CPCS) preferred.