Job title

Provider Network Credentialing Specialist

Department

Medical Management

Reports to

Contracts and Provider Relations Manager

Vice President

Medical Management

Updated

May 2023

Nature of Work in this Position: The primary responsibility of this position is to carry out the functions of credentialing and re-credentialing of individual healthcare practitioners, practice group and facility organization based on the company’s established Credentialing Program; assist in the coordination and maintenance of the organization’s provider contracting tasks as well as the company’s provider, government and community relation activities; acts as company liaison with various entities.

Illustrative Examples of Work:

· Coordinates the company’s provider recruitment and credentialing activities. This includes activities related to establishing and maintaining an effective and viable provider network.

· Provide orientation to new providers and maintain an effective and cordial relationship between company, members and practitioners.

· Receive credentialing application and supporting documents, and reviews these documents to ensure its completeness of the requirements and accuracy of information.

· Maintain credentialing documents and performs review, research and verification of credentialing requirements, including but not limited to licenses, certifications, registrations, permits, educational degrees, association memberships and any related electronic systems and software such as but not limited to the National Practitioners Database, National Student Clearinghouse -Degree Verify and the OIG List of Excluded Individuals and Entities.

· Updates and maintains provider information and status changes (such as licenses & certification dates, tax identification numbers, contact information, (etc.). Compiles and maintains current and accurate credentialing documents for all providers.

· Address and responds to telephone and written inquiries from providers, members and other departments, pertaining to provider participation and credentialing status in a professional and courteous manner.

· Conduct off-site facility audits as part of credentialing and recredentialing review, as needed.

· Routinely performs review- fraud detection audit, debarment, delisting of provider network to comply with the Office of Inspector General–Administrative Sanctions Department.

· Assists in the development and execution of provider performance evaluation; reviews provider compliance of the company’s Credentialing and Quality Improvement program standards. Makes recommendations for retention or delistment of network providers to the Credentialing committee.

· Assist in the implementation of strategic Quality Improvement plans, programs, policies, and guidelines in alignment with accreditation standards and HEDIS-like quality metrics. This includes providing recommendations for performance improvement initiatives, corrective action plans that support the Quality Improvement program’s Key Performance Indicators (KPI) related to member and provider performance.

· Conducts population and network provider assessment for both short and long term access and availability of quality health care for members.

· Assists in provider negotiation, research, and establishment of fee schedule to ensure appropriate compensation of providers, as needed. This includes collecting, collating, analyzing reports and provider reimbursement and utilization data for use in contract negotiations and policy creation.

· Create, develop and maintain a provider profile, credentialing database, directory, and provider manual using Microsoft Office Applications and Adobe Acrobat.

· Writes provider publications such as monthly newsletters, memos, letters and communicates these messages via email, website, provider portal or conduct face-to-face provider education on company policies, processes & programs, and lead proactive orientation seminars with individual providers and provider groups. Releases external and internal communication regarding provider contract and policy issues.

· Provides support to the Marketing & Sales department in all public marketing campaigns via review of printed materials, event planning, coordination and participation.

· Participates in the Credentialing Committee meetings and other Quality Improvement Program activities.

· Maintains close coordination with the Quality Assurance, UM Informed Choice, Health Management, Customer Care, Claims, Actuarial and Underwriting, and Marketing & Sales Departments in enhancing provider and customer satisfaction.

· Coordinates with other departments and ensures timely handling of provider appeals, complaints and grievances.

· Keeps current on Federal and local legislation / regulations affecting health insurance.

· Prepares activity report and maintain the confidentiality of information processed.

· Performs related duties as required. (Related duties are duties that may not be specifically listed in the class specification or position description, but that are within the general occupational series and responsibility level typically associated with the employee’s class of work.)

Knowledge / Skills / Abilities:

· Significant organizational skills.

· Strong verbal and written communication.

· Attention to detail and quality focused.

· Ability to multi-task and manage time efficiently.

· Ability to read, analyze and interpret technical journals, worksheets, financial reports, and legal documents (e.g. contracts).

· Ability to respond to common inquiries, complaints from providers, customers, outside agencies, or members of the health care community.

· Ability to construct letters, reports that conform to prescribed style and format.

· Ability to conduct effective presentations to management, provider groups and customers.

· Ability to work effectively with employees and the public.

· Ability to work under the stress of meeting many requests from various departments and individuals, sometimes with conflicting deadlines.

· Knowledge of Medicare and HIPAA rules and regulations.

· Familiarity of federal and state laws and requirements relating to healthcare credentialing management.

Minimum Experience and Training:

Any combination of education and experience, providing the required skill and knowledge for successful performance would be qualifying. Typical qualifications would be equivalent to:

• A Bachelor’s or Associates degree in healthcare related field or equivalent;
• Minimum of two (2) years’ experience in credentialing, contracting or health insurance is preferred;
• Proficient in the use of Adobe Acrobat and Microsoft Office (Excel, Word, PowerPoint, Outlook, Teams);
• Computer literate (Windows)

Other Requirements

• Valid driver's license
• Use of personal vehicle

Note: This job specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.

Job Type: Full-time

Pay: $12.53 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Education:

• Associate (Preferred)

Experience:

• Credentialing, contracting, or health insurance: 2 years (Preferred)

Work Location: In person

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