Credentialing Specialist

Posted on: 4/20/2014 11:45:00 PM
Job Type: Full-time
Salary: Competitive

 Job description:

Responsible for credentialing activities as it relates to initial credentialing, re-credentialing, and credentials modification. Tracking of issues associated with activities necessary to maintain and document ongoing compliance.

Duties include but not limited to :

·         Use CMS guidelines and internal policies and procedure to create credential provider applications for enrollment into the Medicare Part  B. as well as many other insurance carriers.

·         Experience with PECOS, MCS and/or FISS, NPPES, and CAQH is required.

·         Leads the credentialing process by entering/logging/scanning information into credentialing system for initial, updated, add on applications and maintenance processes.

·         Acts as the point person for completing and ensuring compliance and delivery of required information to insurances in a timely manner.

·         Process and maintain credentialing and re-credentialing in accordance with MAR policy and procedure, CPC policy and procedures, Joint Commission standards, State and Federal Regulatory regulations.

                This will include but not limited to the following verifications:

                National Practitioner Data Bank OIG/GSA for Medicare/Medicaid exemption
                DEA Verification Licensure
                Board Certification Training verified. Residency/ Fellowship
                Peer Recommendation Professional Schooling Verified


·         Ensure that all credentials files are current and complete pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage, DEA and other pertinent information.

·         Monitor collection of all information received; follow up on missing items and/or incomplete forms, submit follow up requests for verifications as needed

·         Identifies and evaluates potential red flags and works in collaboration with doctor to document the issue and doctor response.

·         Advise Manager and/or Director of questionable information received and any issues identified during the processes.

·         Submit closed files for audit/final review and secure missing items as identified by audit/final review

·         Maintain all credentials files ensuring that all correspondence in the credentialing and reappointment process is accurately filed; is knowledgeable and current on the process and legal/regulatory requirements

·         Assure confidentiality of data

·         Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”

·         Perform other duties as assigned





·         5+ years’ experience in the managed health care industry including extensive experience with provider credentialing. This could include provider credentialing experience with health plans, on behalf of a provider organization, or with a vendor.

·         Able to work with minimal supervision and works well in both individual and group environment.

·         PC Skills - demonstrates proficiency in Microsoft Office (Outlook, Excel, Access, Word) applications and others as required.

- NAMSS certified as CPCS preferred but not required.

·         Great communication, customer service skills

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