Provider Enrollment Specialist

About the role

The Credentialing Specialist is responsible and accountable for accurate and timely provider credentialing, to include new applicant credentialing, re-credentialing and ongoing maintenance of provider credentials and reports as required by commercial, federal and state payer and other regulatory or agency requirements.

Responsibilities

• Performs accurate and timely provider credentialing, to include new applicant credentialing, re-credentialing and ongoing maintenance of provider credentials and reports as required by commercial, federal and state payer, hospitals and other regulatory or agency requirements.
• Responsible for accurate and timely collection and data entry of CAQH, DEA, licensure and other provider enrollment requirements.
• Creates and facilitates completion of clinician applications for payer and facilities to ensure timely credentialing and enrollment.
• Prepares application packet to send out to providers.
• Assists in maintenance of listing of “pending applications.”
• Receives application from potential applicant; review application for completeness/accuracy and initiate processing, including primary source verification, OIG query, Criminal Background Check submission, and third party payers, CAQH and other related credentialing applications.
• Compiles and maintains organized computer files, paper files and data for immediate access and retrieval of materials.
• Maintains files according to established policy for record retention.
• Input data in various systems (credentialing software, hospital main-frame/Eclipsys, etc.).
• Maintains credentialing management documents, tracks credentialed providers for re-credentialing.
• Notifies risk management for certificate of insurance (COI) and NPI number applications.

Requirements

• High school graduate or GED.
• College degree preferred.
• Three years of experience in a related field required.
• Knowledge of medical terminology, computer skills and third party payer credentialing processes preferred.
• Ability to relate well with consumers, companies and multiple departments.
• Ability to effectively gather and exchange information in both oral and written communications and bookkeeping skills.
• Self-starter with ability to meet deadlines and maintain organized files.

Working Conditions

Normal office environment with little exposure to excessive noise, dust, temperature and the like.