Credentialing Specialist
 

FLSA Class: Non-Exempt
Department: Operations
Job Category: Administration
Reports to: Chief Operating Officer

Summary Description: The Credentialing Specialist is responsible for managing the credentialing and re- credentialing functions and maintaining all corporate provider information in files, databases and spreadsheets.

Essential Functions: To perform this job successfully, an individual must be able to perform the following satisfactorily; other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Oversee the provider credentialing and re-credentialing function for the organization utilizing applicable resources.
  • Manage provider credentialing processes and procedures to meet time-sensitive deliverables, including notification and follow up with other departments directly involved in oversight.
  • Assist with daily business operations including obtaining the necessary information to credential and re-credential providers.
  • Assist with the resolution of non-responsive providers to credentialing and re-credentialing to ensure all efforts are made to keep providers in compliance according to standards and regulatory requirements.
  • Prepare and maintain reports of credentialing activities such as accreditation, membership or facility privileges ensuring that all information meets federal and state guidelines.
  • Maintain thorough knowledge of organizational policies and procedures, NCQA and CMS and other related accreditation standards, state guidelines, and regulatory requirements.
  • Manage all delegated relationships pertaining to credentialing.
  • Attend required meetings and participates in training programs as required.
  • Understand and adhere to HIPAA policies, procedures and regulations to ensure and maintain patient confidentiality.
  • Contributes to team effort by accomplishing related results as needed.

Education: 

  • High school diploma or equivalent required.
  • Bachelor’s degree or equivalent experience preferred.
  • 5-7 years’ of experience in a credentialing/operations role.

Requirements: 

  • A track record of delivering successful results.
  • The ability to set priorities and work independently while maintaining a high degree of accuracy.
  • Adapts to new technologies. Demonstrates required skills. Keeps technical skills up to date.
  • Integrates changes smoothly. Prioritizes and plans work activities.
  • Uses time efficiently.
  • Follows instruction. Keeps commitments. Meets attendance and punctuality guidelines. Responds to requests for service and assistance.
  • Takes responsibility for own actions.

Computer Skills:

  • Proficient in MS Office software; particularly Excel and Outlook.

Competencies:

  • Communications - Expresses ideas and thoughts verbally. Expresses ideas and thoughts in written form. Exhibits good listening and comprehension. Keeps others adequately informed. Selects and uses appropriate communication methods.
  • Customer Service - Displays courtesy and sensitivity. Manages difficult or emotional customer situations. Meets commitments. Responds promptly to customer needs. Solicits customer feedback to improve service.
  • Dependability - Responds to requests for service and assistance. Follows instructions, responds to management direction. Takes responsibility for own actions. Commits to doing the best job possible. Keeps commitments. Meets attendance and punctuality.
  • Planning & Organization - Prioritizes and plans work activities. Uses time efficiently. Plans for additional resources. Integrates changes smoothly. Sets goals and objectives. Works in an organized manner.
  • Quality - Demonstrates accuracy and thoroughness. Displays commitment to excellence. Looks for ways to improve and promote quality. Applies feedback to improve performance. Monitors own work to ensure quality.
  • Use of Technology - Adapts to new technologies. Demonstrates required skills. Keeps technical skills up to date. Troubleshoots technological problems. Uses technology to increase productivity.

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

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit; use hands to finger,
handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to
stand; walk; climb or balance and stoop, kneel, crouch, or crawl. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Travel: No travel is expected for this position.

Other Duties: This job description is not intended to cover or contain a comprehensive listing of activities, duties, standards or responsibilities that are required of the employee for this position. Duties, responsibilities and activities may change at any time with or without notice. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.

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