Credentialing Specialist

About the role

The Credentialing Specialist will ensure the delivery of high-quality care to members by monitoring and maintaining the integrity of dental provider data in compliance with industry standards and regulatory requirements. They provide integral support to dental operations by enabling timely onboarding of dental providers.

Responsibilities

• Collaborates professionally with dental health care providers, offices and staff to collect relevant data to ensure accuracy of records.
• Ensures potential New Provider applications meet credentialing standards prior to being credentialed.
• Ensures accurate entry and maintenance of data utilizing various resources and search databases.
• Compiles and analyzes data to ensure completeness and accuracy of records and information.
• Displays sound judgement by escalating inaccurate and/or contradicting data to Supervisor and Clinical committees.
• Reviews and screens initial and recredentialing applications for completeness, accuracy, and compliance with federal, state, local and regulations, guidelines, policies, and standards.
• Covers primary source verification, collects, and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to NCQA credentialing standards.
• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to credentialing Manager for sound decision making in accordance with Medical Staff Bylaws, credentialing policies and procedures, federal, state, local and government/insurance agency regulations.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
• Processes weekly CDT reports.
• Processes bi-weekly On-Going Monitor report.
• Prepares forms and reports to be completed by Dental Director.
• Sends follow up and termination correspondence to Providers after review from Dental Director and / or Credentialing Committee.
• Collects missing information via phone, fax, and/or letter from current providers in order to complete the re-credentialing process.
• Documents credentialing decisions of the Dental Director.
• Acts as subject matter expert to assist other departments with credentialing information.
• Communicates and interacts effectively and professionally with co-workers, management, customers, etc.
• Maintains complete confidentiality of company business.
• Maintains communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Qualifications

• Bachelor’s degree and 5 years of credentialing, health provider relations or related experience OR 9 years of credentialing, provider relations or healthcare administration related experience.
• Ability to communicate effectively both orally and in writing.
• Customer service skills.
• Ability to respond to emails timely and effectively.
• Information research skills.
• Knowledge of dental provider credentialing and accreditation principles, policies, processes, procedures, and documentation.
• Working knowledge of clinical and/or hospital operations and procedures.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications.
• Ability to make administrative/procedural decisions and judgments.
• Demonstrated advanced working knowledge of Microsoft Word and Excel.
• Advanced skills in computerized spreadsheeting and database management.