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• Update outdated provider credentialing and demographic information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