Provider Credentialing Spec
Job Summary
The Provider Credentialing Specialist supports the Credentialing Department by managing and maintaining accurate, up-to-date provider data to include updates, changes, additions and terminations in the credentialing, while working under timeline, accuracy and production targets.
Performs credentialing activities including : primary source verifications, communicating with Providers to request missing information supporting the integrity of Provider data in all downstream systems, and key-entering initial data of potential network Providers into the credentialing system.
Veterans and Military Families encouraged to apply
Education & Experience
Required :
- High School Diploma or GED
- 6 months or more of provider credentialing experience
Preferred :
- 1+ years of credentialing experience
- Experience using provider credentialing software systems or Provider Data Management Systems
- Knowledge of URAC or NCQA standards
Key Responsibilities
- Process Provider credentialing inventory within expected timeline, accuracy and production targets.
- Update outdated provider credentialing and demographic information
- Reviews Provider applications and verifies that each meets all credentialing criteria.
- Reviews Provider applications for accuracy and completeness and follows-up to obtain missing information materials in a timely manner and in accordance with department standards.
- Queries primary sources, as applicable, to verify Provider credentials and qualifications.
- Prepares files for review by the Credentialing Committee
- Maintains current credentialing, directory status information in a Provider credentialing system (Provider database.)
- Represents the Credentialing Unit at Credentialing Committee meetings as needed.
- Achieves and maintains required department credentialing timeframe standards.
- Communicates, though both written and verbal communication, in a professional and concise manner and is able to share information and / or instructions for updating and correcting Provider credentialing databases.
- Coordinate with internal departments for Provider database related issues.
- Works with Credentialing Verification Organization(s) as directed.
- Perform other duties as assigned.
- Regular and reliable attendance is required.
Competencies
Commitment to Task : Ability to conform to established policies and procedures; exhibit high motivation.
Communication / People Skills : Ability to influence or persuade others under positive or negative circumstances; Adapt to unique styles;
Listen critically; Collaborate.
Computer Literacy : Ability to function in a multi-system Microsoft environment using Word, Excel, Outlook, TriWest Intranet, the Internet, and department software applications.
Organizational Skills : Detail-oriented with the ability to organize people or tasks, adjust priorities, learn systems, within time constraints and with available resources.
Problem Solving / Analysis : Able to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues.
Technical Skills : Proficient with key databases, including credentialing software systems, Provider Data Management Systems, and Provider Information Management Systems;
working knowledge of Provider credentialing policies and procedures, healthcare or managed care experience