Credentialing Specialist

Job Description

Job Description

Position Summary:

The Credentialing Specialist is responsible for the timely and compliant initial credentialing process for allied providers and physicians according to state and federal requirements, NCQA accreditation standards, Medicare and Medicaid guidelines, and Community Care Plan (CCP) Credentialing policies and procedures.

Essential Duties and Responsibilities:

1. Credentials new/initial providers from inception through completion for all applicable lines of business.
2. Contacts providers and designated credentialing administrators to obtain all necessary documentation to initiate and complete the full credentialing cycle.
3. Validates documents to ensure accuracy of all credentialing elements, completeness of information, and qualifications relative to accreditation credentialing standards, state and federal guidelines, and CCP criteria.
4. Creates, updates and maintains provider records in credentialing database focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
5. Electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of initial credentialing applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.

1. Conducts primary source verifications and oversight to ensure providers meet all necessary qualifications, including education and training, board certification, Florida state licenses and certifications.
2. Screen providers across various systems, platforms, and databases such as the National Practitioner Database (NPDB), System for Award Management (SAM), the Office of Inspector General (OIG), the Agency for Healthcare Administration (AHCA), Social Security Death Master File (DMF), NPI registry, and the Florida Medicaid Provider Master List (PML).
3. Confirms provider hospital affiliations, work history, malpractice insurance or self-insurance status, and Tax Identification Number.
4. Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners.
5. Maintains inter-departmental relationships with Provider Operations and Provider Data Management teams to ensure efficient, timely, and accurate processing of provider applications, and network enrollments, updates, and terminations.
6. Prepares provider files for presentation to CCP Credentialing Committee for determination at least monthly.
7. Responsible for ongoing monitoring and review of dashboard alerts related of possible sanctions and exclusions, and expiring licenses or certificates for all active providers in the credentialing database system.
8. Reports problems to Credentialing Supervisor and makes sound decisions in accordance to credentialing policies and procedures, federal, state, local and government/agency regulations.
9. Responds to internal and external inquiries regarding credentialing status.
10. Acts as backup to Credentialing Coordinator on the Credentialing Hotline as needed.
11. Maintains professional growth and development through seminars, workshops, professional affiliations, and self-education, including staying current with the department policies and procedures, to keep abreast of latest developments to enhance understanding of various regulations and legislation of the healthcare industry
12. Performs miscellaneous job-related duties as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

• Associates degree, or equivalent combination of education and experience (preferred).
• Three (3) years of credentialing or onboarding experience, or combination.
• Must have working knowledge of managed care or healthcare environment.
• Project management experience or certificate (preferred).
• Two (2) years records and/or database management experience.
• One (1) year of customer service experience.
• Epic Tapestry system experience (preferred).
• Proficient in Microsoft Word and Excel.

Skills and Abilities:

• Analytical skills
• Detail-oriented
• Self-directed
• Exhibit independent judgment
• Results-oriented
• Self-motivated
• Communicate proficiently in English
• Professional oral and written communication skills
• Project management skills
• Information research skills
• Define problems, collect data, establish facts, and draw valid conclusions
• Read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents
• Respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community
• Maintain strict confidentially and handle sensitive information
• Ability to learn new applications to function effectively in a remote work environment
• Establish priorities with independent coordination of day-to-day aspects

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.