Credentialing Specialist

About the role

Develop and cultivate productive relationships with providers, retail chains, strategic partners, and their staff. Elevate providers’ understanding of industry-standard credentialing requirements by leveraging team knowledge and resources. Establish relationships with providers to obtain required regulatory information and manage all aspects of the provider’s initial and ongoing credentialing requirements. Use independent judgment to ensure documentation complies with appropriate state regulations.

Responsibilities

• Oversee and manage assigned files in the CVO partner’s system.
• Track in-progress credentialing files, identify and collect missing documents to ensure timely completion of the credentialing process for new and existing providers, and ensure state regulatory standards are met.
• Research, analyze, and resolve complex credentialing issues and escalations, coordinating with internal and external business partners to meet regulatory compliance requirements.
• Use analytical and investigative skills to collect, evaluate, and compile information from regulatory reporting agencies, legal documents, and providers to support explanations of provider sanctions and/or malpractice claims.
• Compile required information for the Credentialing Committee in a clear and complete format to enable decision-making on provider applications.
• Exercise critical thinking and analytical skills in the initial entry and maintenance of provider data to ensure the integrity of all shared provider information.
• Escalate issues to appropriate business areas and drive solutions when applicable.
• Gather and assess necessary provider information for the legal department to support the Dispute Resolution Process for providers denied at Committee or terminated from the network.
• Compose professional and concise correspondence to providers, retail chains, and office staff.
• Demonstrate a broad knowledge of the organization's strategic direction to achieve growth objectives and operational goals, acting as an internal resource for business partners.

Requirements

• Bachelor’s Degree in a related field; in lieu of a degree, 4 years of functional experience.
• Demonstrated professionalism and leadership in dealing with situations involving controversy and conflict, with experience handling and resolving escalated issues.
• Demonstrated advanced communication, influencing, and problem-solving skills.
• Experience working directly with providers and staff on credentialing policies and procedures.
• Regularly exercise discretion and independent judgment in the performance of job duties.
• Demonstrated ability to identify problems and provide creative solutions.
• Strong attention to detail, multitasking, organizational skills, and customer service skills.
• Proven ability to balance provider needs with corporate objectives.
• Ability to work independently and in a team environment.

Pay

Salary range: $58,656.00 – $80,253.00. Applicable salary ranges may differ across markets. Actual pay will be determined based on experience and other job-related factors permitted by law. This role may include eligible bonuses and commissions.