Credentialing Specialist

About the role

Join Paradigm and help support the credentialing and re-credentialing of healthcare providers who make a difference in the lives of patients with complex injuries and diagnoses. We're looking for a detail-oriented professional who thrives in a fast-paced environment and enjoys working collaboratively to ensure quality, compliance, and exceptional service. As a four-time Great Place to Work® and three-time Fortune Best Workplaces in Health Care™ recipient, Paradigm offers a culture where you can grow, contribute, and make an impact every day.

Responsibilities

• Completes credentialing and re-credentialing application process of all internal and affiliated community practitioners.
• Processes request, investigation, verification, tracking and follow up of primary responses from various sources.
• Identifies, investigates, reports, tracks, and follows-up on any potentially adverse information received from credentialing sources.
• Obtains and maintains appropriate knowledge of company policy and procedures, accreditation standards, state and federal regulations, guidelines, procedures and laws required in credentialing process.
• Populates, updates, and maintains credentialing software and filing systems.
• Assists with Requests for Proposals or any requested reports as necessary and in collaboration with supervisor or other Credentialing Services staff.
• Maintains practitioner files annually.
• Ensures medical licenses, DEA certificates and malpractice certificates are current at all times for affiliated community practitioners.
• Works with designated QAIR Peer Review and Member Services personnel prior to each Credentialing/Peer Review meeting and continuously coordinates Peer Review information into credentialing and re-credentialing files.
• Collects site visit information from Provider Relations on appropriate practitioner files in preparation for Credentialing/Peer Review Committee approval meetings.
• Works with Risk Management to identify and coordinate any risk management, substance abuse and/or malpractice issues. Reviews files for any "red flag" issues.
• Prepares practitioner profiles and completes permanent file for review and approval at each Credentialing/Peer Review Committee meeting.
• Participates in professional organizations and/or other organizations addressing credentialing, compliance and/or risk management activities.
• Maintains strict confidentiality of all records, data and occurrences as condition of initial and/or continued employment.
• Maintain reliable and predictable attendance during scheduled work hours.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. Adopts new technologies as trained and applies them in alignment with established processes and guidelines.
• Demonstrates a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.
• Responsible for complying with Paradigm Information Security requirements and policies, for safeguarding Paradigm or Paradigm related passwords, and for notifying Paradigm of any Information Security incidents per policy SEC 10-12 Information Security Incident Management.

Qualifications

• Bachelor's degree in health care or technical field preferred, call center experience a plus.
• Exceptional communication and telephone skills required, as well as a great deal of patience and understanding.
• Experience working with physicians and/or senior executives preferred.
• Possess a high level of self-confidence and persistence; maintain an assertive approach in dealing with providers.
• Must possess excellent organizational skills and the ability to multi-task effectively.
• Demonstrate the ability to prioritize heavy workload and work independently with minimal supervision.
• Proficient computer and internet skills; familiarity with Microsoft Office software required.
• Knowledge of medical terminology preferred.
• Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator (CMSC) by the National Association Medical Staff Services (NAMSS) preferred.
• Will develop in-depth knowledge of department and company internal workflows including, but not limited to individual state’s procedures and negotiating protocols.
• Bilingual a plus.