Credentialing Specialist

Job Description

Job Description

About Company:

We are a privately-owned physician network in the Charlotte, NC Metro Area. We operate in the fast-paced, ever-evolving, managed care space. Our work is challenging and especially enjoyable in our family-like atmosphere. We offer excellent compensation and a competitive benefit package, AND most every week, only work 37 hours. We keep our work exciting and fun, while at the same time striving to provide innovative services and solutions to make healthcare more accessible, more effective, and more affordable for everyone!

Job Description:

The Credentialing Specialist coordinates and performs a variety of duties that are required for processing applications for credentialing applicants and recredentialing existing network providers. In this position, working alongside the Director of Credentialing, you will perform a series of activities designed to lead to a decision to accept or reject a provider’s application to participate as a new provider in the network and an existing provider’s application to continued participation. The credentialing process is performed in accordance with the company’s policies and procedures designed to ensure compliance with applicable laws, regulations, third-party standards, and policies.

**This is an in-person position.**

Essential Functions/Job Responsibilities:

• Sends providers credentialing and recredentialing application packets
• Ensures received application packets contain all required information
• Advises applicants of critical timelines
• Completes electronic logs that track application status and ensures adherence to various deadlines
• Establishes files for all credentialing applicants and recredentialing files for existing network providers
• Conducts credentialing activities and steps within strict predefined timelines
• Maintains knowledge of current payor, agency, and third-party requirements for credentialing providers, including, but not limited to, NCQA, URAC, and CMS standards
• Reviews credentialing and recredentialing files to ensure that they meet NCQA, URAC, and CMS standards, and payor and company requirements
• Performs primary source verification as required by NCQA, URAC, and/or CMS standards, and/or payor requirements
• Contacts providers to obtain missing or incomplete information for resolution
• Enters provider data in the electronic records database according to established procedures
• Completes verification checklists that document the completion of credentialing tasks and their corresponding timelines
• Prepares files for review by the company’s Credentialing Committee
• Notifies providers of credentialing decisions
• Ensures that credentialing is conducted in a nondiscriminatory manner
• Ensures the confidentiality of all information that is obtained during the credentialing process
• Maintain knowledge of current health plan information and agency requirements for credentialing providers
• Demonstrate and maintain the standards and requirements of the Health Insurance Portability and Accountability Act, (HIPPA); while ensuring the protection and security of personal, confidential, and identifiable information in a professional and responsible manner and carry out all measures to prevent unauthorized disclosures
• To understand and demonstrate compliance with Health Network Solutions program requirements
• Be a steward for the mission of Health Network Solutions
• Performs additional duties and functions as assigned

Education/Experience Requirements:

• High School Diploma or GED is required
• Bachelor’s degree in Business, Healthcare Administration, Communications, or a related field is preferred; however, equivalent work experience and education will be considered in lieu of a degree
• 1-2 years prior office experience in credentialing healthcare providers for a hospital, provider network, or payor

Competencies:

• Excellent customer service skills, interpersonal skills, communication skills (both oral and written) to effectively communicate with providers, providers’ staff and co-workers
• Strong organizational and time management skills
• Ability to make timely informed decisions that consider the facts, goals, constraints, and risks related to all aspects of the organization.
• Detail-oriented
• Strong critical thinking skills necessary to evaluate provider application data for accuracy and completeness
• Ability to handle situations/issues with tact and diplomacy
• Ability to work well with individuals from diverse backgrounds
• Ability to maintain confidentiality, adhere to compliance policies, and ensure that all confidential/PHI documents are kept in secure locations
• Ability to multi-task, prioritize, and adhere to timelines
• Basic computer skills including MS Office programs

Job Type: Full-time

Benefits:

We offer full benefits, including paid medical, dental, vision, and more; plus, paid holidays and paid time off; 401k (with company match); 37-hour workweek (most every week); and a great work environment!