Credentialing Specialist

Summary:

• Candidates should have knowledge of NCQA standards, delegated credentialing, and Primary Source Verification.
• Candidates should have knowledge of health plan credentialing and enrollment including Medicare and Medicaid.
• Ability to prepare and/or update the provider’s CAQH application for newly affiliated and existing healthcare providers for initial and recredentialing activity.
• The ability to build and maintain peer-to-peer relationships with all relevant market and national health plans.
• Establish credentialed status to facilitate billing for multiple specialties.
• Maintain and update credentialing databases completely and accurately and ensures up-to-date tracking of file process.
• In-depth working knowledge of the various applications associated by plan as well as internally and the workflow process defined by department leadership.
• Ensure all workflow items are completed within the set turn-around-times, meeting quality expectations.
• Roster management and reporting experience preferred

Qualifications:

• High School Diploma or equivalent required; completion of an applicable Vocational or Technical training program preferred.
• Minimum of two years of experience in a credentialing role or related health care environment (such as credentialing or file maintenance) or heavy customer service background preferred.
• Strong Microsoft Excel skills (vlookups, pivot tables, etc.) is required.
• Must have the ability to travel up to 10% nationally.
• Understanding of Medicare and Medicaid enrollment (multiple states) as well as experience in navigating government portals preferred.
• Knowledge of health plan credentialing, enrollment, and requirements.
• Knowledge of CAQH.
• Baseline knowledge of revenue cycle.
• Ability to work within a deadline-intense environment.
• Demonstrated problem-solving and customer service skills.
• Knowledge of Microsoft Word and other PC applications.
• Excellent verbal and written communication skills.

#LI-SG1