Credentialing Specialist

Summary: Candidates should have knowledge of NCQA standards, delegated credentialing, and Primary Source Verification. Candidates should have knowledge of health plan credentialing and enrollment including Medicare and Medicaid. Ability to prepare and/or update the provider’s CAQH application for newly affiliated and existing healthcare providers for initial and recredentialing activity.

The ability to build and maintain peer-to-peer relationships with all relevant market and national health plans. Establish credentialed status to facilitate billing for multiple specialties. Maintain and update credentialing databases completely and accurately and ensures up-to-date tracking of file process. In-depth working knowledge of the various applications associated by plan as well as internally and the workflow process defined by department leadership.

Ensure all workflow items are completed within the set turn-around-times, meeting quality expectations. Roster management and reporting experience preferred Qualifications: High School Diploma or equivalent required; completion of an applicable Vocational or Technical training program preferred. Minimum of two years of experience in a credentialing role or related health care environment (such as credentialing or file maintenance) or heavy customer service background preferred.

Strong Microsoft Excel skills (vlookups, pivot tables, etc.) is required. Must have the ability to travel up to 10% nationally. Understanding of Medicare and Medicaid enrollment (multiple states) as well as experience in navigating government portals preferred. Knowledge of health plan credentialing, enrollment, and requirements.

Knowledge of CAQH. Baseline knowledge of revenue cycle. Ability to work within a deadline-intense environment. Demonstrated problem-solving and customer service skills. Knowledge of Microsoft Word and other PC applications. Excellent verbal and written communication skills. #LI-SG1