Credentialing Specialist

Overview

Credentialing Specialists work to ensure verification of the professional licensing, training, and certifications of professional licensed independent practitioners, Advanced Practice Professionals, and others. Their primary goal is to ensure healthcare professionals and services meet all established federal and state standards, as well as NCQA (National Committee for Quality Assurance) standards. This is a fully remote opportunity.

Duties & Responsibilities

• Compile confidential, accurate primary sourced data to facilitate customers in the decision-making process for practitioners/providers with health care plans, hospitals, surgery centers and/or other health care institutions. Position requires extensive, direct interaction with health plans, government agencies, practitioners/providers, and customers.
• Process, review and maintain all practitioner/provider credentialing and re-credentialing files and offer solutions regarding the workflow of credentialing files.
• Enter and update practitioner/provider data in the credentialing database while adhering to input standards.
• Processes complete initial and re-credentialing applications within the expected timeframes.
• Perform primary source verification in accordance with customer needs and applicable industry standards.
• Assure the confidentiality and integrity of all aspects of the credentialing program and process.
• Perform a variety of essential administrative functions for all aspects of the credentialing, and follow up processes.
• Must be able to interpret and communicate primary sourced data/information in a timely manner and understand current state and federal regulatory requirements, accreditation standards, as they pertain to primary source verification functions.

Skills Required

• Solid working knowledge of credentialing software applications and/or other relational databases like Access.
• Excellent organizational skills.
• Superior customer service skills.
• Excellent communication skills - both verbal and written.
• Understands the importance of customer follow up and attention to detail.
• Must be highly organized and able to work efficiently and effectively in a fast-paced environment.

Qualifications Required:

• Must have Primary Source Verification experience and be able to speak to the databases used for PSV. 
• Direct and recent working experience dealing with healthcare credentialing in a hospital, CVO or other setting where adherence to policy and other regulatory standards are essential.
• Certification as a CPCS (Certified Provider Credentialing Specialist) by NAMSS preferred but not required.

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