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Credentialing Specialist

Human Resources
Status: 
Full Time
Department: 
Human Resources
Location: 
TBD
Hours: 
8:00 - 5:00
Description: 

MAJOR FUNCTION:
Responsible for implementation and oversight of all activities associated with physician credentialing and re-credentialing process. Conducts ongoing credentialing and re-credentialing due diligence to ensure files are maintained based on accepted standards. Develops credentialing Policies & Procedures and creates reports to track and manage provider status throughout the process. Provides regular status reports to senior management. Interacts regularly with health plans and other payor organizations to ensure accurate provider data are communicated to and maintained by payors.
 
ESSENTIAL FUNCTIONS:
• Responsible for the development of credentialing policies and procedures.
• Oversight and hands on processing of provider applications and re-applications including initial mailing, review, and loading into the database tracking system ensuring high quality standards are maintained. 
• Conducts audits and provides feedback to reduce errors and improve processes and performance. 
• Oversees primary source verification activities. 
• Coordinates, supervises and is accountable for the daily activities of Credentialing Assistants.
• Responsible for integrity of provider data. 
• Coordination and management of provider data disseminated to health plans and other payors.
• Maintain knowledge of NCQA and The Joint Commission physician credentialing requirements.
• Monitor regulatory sources to stay informed of rapidly changing rules and regulations that relate to credentialing processes.
• Attends to other duties as assigned.
• Demonstrates the CARE values in the course of carrying out responsibilities.
• Follow all safety rules while on the job. Reports accidents promptly and corrects minor safety hazards.
 
EDUCATION:
• 3-5 years of experience in professional healthcare staff credentialing with increasing responsibilities.
• Bachelor’s degree preferred or Associates degree with a minimum of 6 years of experience.
 
PREREQUISITES FOR THE JOB:
• KNOWLEDGE OF: NCQA and The Joint Commission credentialing requirements.
• SKILLS: Excellent written and verbal communication; Strong organizational and attention to detail, Proficient in MS Word & Excel.
• ABILITY TO: Motivate and supervise others. Work with minimal supervision, meet deadlines and prioritize tasks; to effectively interact with operational and clinical personnel; collect, correlate and analyze data.
 
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.
• The employee must occasionally lift and/or move up to 25-50 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. 
 
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually quiet.