Payer Credentialing Specialist

Company Conformance Statements

In the performance of their respective tasks and duties all employees are expected to conform to the following:

• Perform quality work within deadlines with or without direct supervision.
• Interact professionally with other employees, customers and suppliers.
• Work effectively as a team contributor on all assignments.
• Work independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations.

Position purpose

Process credentialing and re-credentialing and associated tasks in accordance with The Specialty Alliance policies, standard operating procedures and regulatory requirements applicable to The Specialty Alliance provider network.

Responsibilities/Duties/Functions/Tasks:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Gather and submit in appropriate format required credentialing information for assigned provider/practitioner network
• Collaborate with provider organizations to facilitate timely and effective credentialing of assigned provider/practitioner network
• Monitor and update provider and practitioner status and associated information as appropriate
• Maintain accurate data base, tracking files, etc., for assigned provider/practitioner network
• Conduct primary source verification as appropriate
• Provide accurate and informative status reports
• Continuously track and monitor credentialing status and credentials to ensure accuracy and identify re-credentialing needs
• Ensure compliance with The Specialty Alliance’s policies and procedures as well as established regulatory and contractual requirements
• Conduct thorough review of all credentialing information to ensure compliance with policy, regulatory and contractual requirements
• Maintain corporate provider contract files.
• Maintains knowledge of current health plan and agency requirements for credentialing providers.
• Set up and maintains provider information in online credentialing databases and system.
• Tracks license and certification expirations for all providers to ensure timely renewals.
• Ensures practice addresses are current with health plans, agencies, and other entities.
• Other duties as assigned

Education: High school diploma or equivalent.

Experience: Three (3) to five (5) years of credentialing experience preferred.

Additional Preferred Qualifications:

• Understanding delegated credentialing requirements for the health plans.
• Understanding of hospital credentialing / appointments
• Understanding of national accrediting entities (NCQA)
• Understanding of commercial insurance, Medicare and Medicaid enrollment processes
• Understanding of credentialing terminology
• Experience with primary source verification and associated credentialing sources

Performance Requirements:

• Strong presentation skills
• Excellent communication skills, both written and verbal
• Ability to work with physicians and non-physician providers in a fast-paced environment
• Proficient computer skills (Microsoft applications)
• Ability to multi-task and prioritize
• Self-motivated with initiative; willingness to learn and adopt new strategies
• Strong sense of ethics.

Equipment Operated: This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Work Environment: This job operates in professional office environments.

Physical Requirements: While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 10 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.