Credentialing Specialist - Part Time

Position Overview

Responsible for compiling, entering, processing and maintaining the accuracy and integrity of the enrollment, credentialing and re-credentialing of Providers and PRI facilities with third party payers. Maintains a working knowledge of requirements of Center of Medicaid/Medicare Services (“CMS”), National Committee for Quality Assurance (“NCQA”) and third party insurance.

Essential Duties & Responsibilities

• Responsible for all credentialing processes related to compliance, regulations and billable services.
• Provide initial and reappointment applications to providers for Medicare, Medicaid, commercial and Managed Care Plans.
• Responsible for adding and removing providers to/from insurance panels.
• Review application packages and work with Providers and healthcare department leadership to ensure accuracy of provider identifying information, education, training, certifications, professional affiliations, licensing, claims history and work history.
• Search databases for medical malpractice claims, National Provider Information, and for Medicare/Medicaid and other sanctions.
• Assemble peer review letters, proof of continuing education and health clearance.
• Maintains a working knowledge of requirements of Center of Medicaid/Medicare Services (“CMS”), National Committee for Quality Assurance (“NCQA”) and third party insurance.
• Maintain accurate department database for providers.
• Prepare for and handle audits by managed care companies.
• Provide credentialing verification to other institutions upon request and release from current or past medical staff members.
• Provides routine reports to Providers and support staff regarding the status of participation in insurance plans.
• Provides updates regarding managed care plan credentialing procedure changes and other relevant information.
• Produces management reports regarding operations performance and/or provider credentialing status for internal management and external providers using the organization’s verification services.
• Develops and disseminates credentialing policy and procedures ensuring adherence to legal requirements and best practices.
• Initiates correspondence to providers, users, health plans and others as necessary to obtain requisite credentialing information.
• Inform management regarding the status of departmental operations and provider credentialing issues of concern.
• Communicate clearly with Providers, healthcare leadership and administrative staff as needed to provide timely responses upon request on day-to-day credentialing issues as they arise.
• Add additional tasks as needed and directed.

Qualifications

• Bachelor’s degree preferred
• Minimum of two (2) years of credentialing experience in a hospital/community health center setting
• Must be proficient with PECOS, CAQH, NPPES as well as the credentialing and re-credentialing process
• Computer database skills and word-processing required
• Familiarity with Microsoft Office applications, desirable
• Excellent time management, organizational, and customer service skills
• High degree of organizational skills
• Excellent written and verbal communication skills
• Capable of building strong customer relationships and delivering customer-centric service to internal/external colleagues and candidates for appointments
• A good decision-maker, with proven success at making timely decisions that keep the organization moving forward
• Adept at planning and prioritizing work to meet deadlines in a fast-paced environment
• Consistently achieving results, even under time sensitive conditions
• An effective communicator, capable of determining how best to reach different audiences and executing communications based on that understanding
• Certified Provider Credentialing Specialist (CPCS) certification preferred

Benefits

Project Renewal is an equal opportunity employer. Its long-standing policy has been to embrace the equality of opportunity for all employees and applicants without regard to actual or perceived race, color, national origin, alienage or citizenship status, religion or creed, gender (see separately issued Gender Discrimination policy for more detail), physical or mental disability, age (18 and over), military status, arrest record, marital status, domestic partnership status, genetic information or predisposing genetic characteristic, sexual orientation, status as a victim or witness of domestic violence, sex offenses or stalking, unemployment status or any other basis protected by applicable federal, state and local laws.