Overview:

Credentialing Specialist performs all functions in support of onboarding to include initial credentialing, recredentialing, and credentialing monitoring requirements including, but not limited to, performing a

comprehensive quality review of “non- standard” credentialing/re-credentialing, which includes those files with questionable clinical, quality and/or business issues, provider license monitoring, updates to credentialing database from internal reports and notifications, and initiation of CAQH application process for initial credentialing, initiation of recredentialing process. Additionally, this position is responsible for assisting with the routing of files to and from the medical advisor and to and from the credentialing committee.

Responsibilities:

• Distribute packets for CAQH data, payer documents and MARs packet to new hires

• Primary Source Verification of initial credentialing/re-credentialing files according to NCQA Standards

• Appropriately identify and forward applicant initial and re-cred files which do not meet “standard” requirements to medical advisor and/or credentialing committee, according to established guidelines. Notify timely if any issues are identified and determine next course of action.

• Enter and maintain clinician demographic and credentialing information in credentialing database (IntelliCred) obtained through credentialing application, primary source verifications, internal reports, and notifications

• Facilitate creation and/or updating of CAQH applications for initial credentialing and recredentialing when clinician is onboarding through new hire process or new business development process.

• Participate in credentialing committee meetings to assure committee members have necessary information, explain questionable information contained in file and act as overall resource for general credentialing processes

• Conduct license monitoring process for all providers in accordance with licenses, certificate and boards monitoring policy, to include initiation of letters, reports, and primary source verification of renewals

• Identify issues in clinician's file that require committee review - create a medical review file and

• Obtain all requested data elements per committee chairman's request for file to be completed to present to committee.

• Works with External Payer Credentialing and Medicare Enrollment teams on various credentialing projects and internal interfacing processes.

• Submit information required to risk department to obtain COI prior to start date and in order to complete file with high quality work in a quick and efficient turnaround time.

• Collaborate with recruiting, onboarding, risk management and hiring manager to complete prehire clearance and credentialing process for start date to be confirmed 

Qualifications:

Education Level: High School Diploma or GED

Certifications and/or Licenses:

• Certified Professional Credentialing Specialist (preferred)

Job-Related Experience:

Customarily has at least the following experience: 1 year

• Minimum 1-2 years direct experience in credentialing required - CAQH experience preferred

• Certified Professional Credentialing Specialist certification preferred

• Knowledge of credentialing software (IntelliCred) is preferred

• Working knowledge of NCQA, URAC and/or AAHC credentialing standards