Credentialing Specialist

Description

General Summary : The Credentialing Specialist is responsible for managing and maintaining the credentialing data for our healthcare providers in the credentialing database, ensuring accuracy and compliance with regulatory requirements.

This role will be involved in all aspects of the initial credentialing, re-credentialing, and privileging with area hospitals, health plans, and patient care facilities.

They are also responsible for timely renewal of licensures, certifications and appropriate routing of all credentialing documents, and has the ability to collaborate with internal and external stakeholders.

Supervisory Responsibilities : This position has no supervisory responsibilities.

General Requirements : All duties performed will be done accurately and in a timely manner.

• This position may require driving a company vehicle or a personal vehicle; therefore, employees must successfully complete a motor vehicle history check, possess, and maintain a current valid Texas Driver License, and proof of current insurance to be subject for mileage reimbursement.
• Provide training and support to internal teams and providers on credentialing processes, requirements, and best practices.
• Stay abreast of emerging trends and technologies in credentialing data management, recommending and implementing enhancements to improve efficiency and accuracy.
• Stay informed about industry best practices, regulatory changes, and accreditation requirements related to provider credentialing, ensuring compliance and recommending process improvements.
• Collaborate with the IT team to optimize and enhance the credentialing data management systems and processes.
• Participate in internal and external audits and inspections related to provider credentialing, health plan delegation requests, providing accurate data and documentation as needed.

Essential Job Responsibilities :

• Manage the credentialing data for all healthcare providers, including maintaining accurate and up-to-date provider information, credentials, and certifications.
• Ensure timely and accurate data collection, entry, and verification of provider credentials, including licenses, certifications, education, training, and professional affiliations.
• Conduct thorough and detailed provider credentialing and re-credentialing processes, ensuring compliance with regulatory requirements and organizational policies.
• Collaborate with internal teams, such as provider relations, human resources, contracting, and quality assurance, to obtain and validate provider data and documentation.
• Review and analyze provider applications, ensuring completeness and accuracy of information, and follow up with providers to obtain missing or additional documentation as needed.
• Conduct thorough background checks and verification of provider credentials through primary sources, such as licensing boards, educational institutions, and professional organizations.
• Maintain accurate and up-to-date provider credentialing files and databases, ensuring confidentiality and adherence to all applicable privacy and compliance regulations.
• Monitor and track provider expirable, such as licenses, certifications, and malpractice insurance, and initiate timely renewal processes to ensure uninterrupted provider participation.
• Collaborate with the provider relations team to communicate credentialing status updates to providers, resolving any credentialing-related inquiries or concerns.
• Assist in the preparation of provider credentialing reports, audits, and presentations for internal and external stakeholders.
• Strong organizational and time management skills, with the ability to manage multiple priorities and meet deadlines.
• Excellent communication and interpersonal skills, with the ability to collaborate with internal teams and external stakeholders.
• Strong problem-solving and critical-thinking skills, with the ability to identify and resolve credentialing-related issues.
• High ethical standards and a commitment to maintaining confidentiality and integrity.
• Demonstrated ability to work independently and collaboratively with cross-functional teams.
• Exceptional customer service skills, with the ability to build and maintain positive relationships with internal and external stakeholders.

Education and Training : Minimum high school education or equivalent. Bachelor's degree in Healthcare Administration, Business, or a related field preferred.

Relevant experience may be considered in lieu of a degree.

Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification a plus.

Experience : Minimum of 2-3 years of experience in provider credentialing or a related role within the healthcare industry.

Strong organizational and time management skills, with the ability to manage multiple priorities and meet deadlines.

Excellent communication and interpersonal skills, with the ability to collaborate with internal teams and external stakeholders.

Strong problem-solving and critical-thinking skills, with the ability to identify and resolve credentialing-related issues.

Other Requirements : Computer Skills : Proficiency in Microsoft Office Suite, particularly Excel, for data analysis and reporting.

Strong knowledge of credentialing processes, regulatory requirements, and accreditation standards, such as NCQA, CMS, and The Joint Commission.

Proficiency in using credentialing software and databases. Fast learners would be considered.

Work Environment : Clinic environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements : Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 20 lbs.

Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information : Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Other Duties As Assigned : The above job description is not intended to be an all-inclusive list of duties and standards of the position.

Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.

Qualifications

Skills

Behaviors

Motivations

Education

Preferred

Bachelors or better in Business Administration or related field.

Experience

Preferred

2-3 years :

Minimum of 2-3 years of experience in provider credentialing or a related role within the healthcare industry.

Licenses & Certifications