Credentialing Specialist - Credentialing Resource Office

Responsibilities

The Credentialing Specialist is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing packages as required by hospitals, surgery centers, commercial payers, Medicare and Medicaid.

Manage the full cycle of provider credentialing with insurance carriers
Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications and facility privileging
Maintain credentialing software to ensure all information is accurate and updated
Update each provider’s CAQH database file timely according to the schedule published by CMS
Coordinate with practice on the application for and renewal of all provider licenses; Professional, DEA, Controlled Substance, etc.
Collaborate with practice to obtain all provider data as relates to credentialing and privileging
Manage revalidation requests issued by government payers
Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid
Complete re-credentialing applications for commercial payers and facilities
Credential new providers and current providers with facilities at which they hold staff privileges
Work closely with the CBO and billing staff to identify and resolve any denials or authorization issues related to provider credentialing
Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases
Maintain updated provider rosters and review biannually with major payers
Establish and maintain relationships with payers and adhere to all payer credentialing requirements
Develop and maintain policies and procedures related to credentialing and privileging
Other duties as assigned

Qualifications

Education Required:

Undergraduate degree or equivalent experience

Experience Required:

Minimum of 5+ years’ experience in medical practice business office role including 1-2 years’ experience as a supervisor
Knowledge of provider credentialing and its direct impact on the practice’s revenue cycle
Highly (above average level) detail oriented with excellent follow through to see tasks to completion
Excellent computer skills including Excel, Word and Internet / Cloud based technology
Strong and clear written and verbal communication skills
Excellent customer service skills
Possesses a high degree of self-motivation and produces high quality work with minimal supervision