Credentialing Specialist

Position Overview: The Credentialing Assistant is responsible to ensuring employees licenses and credentials are up-to-date and maintained within the HR and credentialing workflow process. Assists in preparing and submitting credentialing and recredentialing payor applications. Responsible for follow up on the status of applications for providers and payers and keep a detailed log of all pending and completed work. Communicate the results and status of the applications to providers, payers, managers, and co-workers to ensure we are meeting third party billing requirements and State specific regulations.

Specific Responsibilities:

• Reviews onboarding applications from HR for completeness and accuracy.
• Develops credentialing workflows, processes, & policy/procedures for the department including, but not limited to, creating Job Aids, Quick Reference Guides, and FAQ's as needed for internal & external stakeholders.
• Assure compliance with and implement policies/procedures for the accurate and timely processing of credentialing applications for providers and facilities.
• Monitor & notify providers of upcoming expiring certifications, including licensures, and all other state and national required documents necessary for the practitioner and/or facility to legally and ethically perform under their scope of practice.
• Develops and creates weekly reports of the credentialing process utilizing Newport's tracking and revenue reports.
• Completes certification/licensure registry checks to ensure compliance with contractual credentialing standards.
• Responsible for various assigned workflows and daily/weekly/monthly duties.
• Assists with audits.
• Conducts roster reconciliations.
• Creates & updates CAQH provider profiles.
• Completes credentialing applications for third parties and organizes credentialing application packages.
• Ensures certification/licensures are up-to-date and loaded into the tracking system for credential-eligible providers.
• Enters large volumes of data entry accurately for credentialing apps & CAQH database and in a timely manner.
• Conducts roster reconciliations.
• Creates & updates CAQH provider profiles.
• Completes credentialing applications for third parties and organizes credentialing application packages.
• Supports the Contracts and Compliance teams.
• Assist with the Peer Review process and oversight with sites.
• Responsible for aligning job descriptions appropriately with payor and State & Federal requirements.

Education and Experience: High school required, associates degree preferred. Healthcare experience preferred.

Required Qualifications

• CAQH Knowledge & Expertise
• Good interpersonal skills; ability to communicate with providers and office managers.
• Notifying Managed Care of qualifying credential-eligible employees.
• Notify Managed Care of terminating site employees.

Competencies

Leadership: : Effective at building support and promoting success in a team-centered environment which functions using a shared vision.

Customer Service: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.

Job Knowledge: mission/values, keeps job knowledge current, and is in command of critical issues.

Integrity: Upholds personal and professional ethics and values, considering the values of the organization and respecting the culture, beliefs, and abilities of individuals.

Ability to deal with difficult people: The ability to respond to difficult client behavior with diplomacy and tact, including defusing anger, creating rapport and influencing behavior.

Resilience: Must be able to cope with stressful and adverse situations, rebound quickly, and then learn from experience.

Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.

Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.

Travel: None to minimal travel