Credentialing Representative Job Description

Credentialing Representative Job Description

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Credentialing representative provides mentoring to staff members; performs internal audits on credentialing and re-credentialing files for accuracy and maintains compliance with credentialing policies and procedures; maintains knowledge of and compliance with TJC, NCQA, CAHQ, and CMS standards, as appropriate.

Credentialing Representative Duties & Responsibilities

To write an effective credentialing representative job description, begin by listing detailed duties, responsibilities and expectations. We have included credentialing representative job description templates that you can modify and use.

Sample responsibilities for this position include:

Act as the primary credentialing contact and provide credentialing support to regional health plans
Solve complex problems on own
Work closely with the Credentialing Coordinator to ensure all necessary paperwork is timely and accurate
Provide technical and administrative support for the Credentialing Processing Center including
Work independently with a team to identify, track, and resolve application issues
May oversee primary source verification activities.Employees in jobs labeled with SCA must support a government Service Contract Act (SCA) agreement
Utilizes credentialing database to maintain credentialing data including, but not limited to creating new hire credentialing profiles, ongoing credentialing updates, such as primary source verifications, immunization records, annual TB documentation, Maintenance of the HR Credentialing inbox by reviewing documents, renaming submissions and distribution of 24 hour responses to team members and managers
Performs professional reference checks, verification of employment/education and partners with HR leadership to make recommendations on hiring decisions based on company policy and vendor adjudication grid
Responsible for ensuring the best possible candidate experience as it relates to pre-employment onboarding, including consistent follow up with candidate and vendor on the status of all information and documentation needed to successfully complete background and drug screening
Prepares ad hoc and recurring credentialing reports and statistics

Credentialing Representative Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Credentialing Representative

List any licenses or certifications required by the position: GLBA, FCRA, CPCS, DPPA

Education for Credentialing Representative

Typically a job would require a certain level of education.

Employers hiring for the credentialing representative job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Associates, Education, Healthcare, Pharmacy, Management, Business/Administration, Business, Health Care Management, Finance, Health Care

Skills for Credentialing Representative

Desired skills for credentialing representative include:

Adapting to changes in a positive manner
Company and department
Correct English
Proper grammar and spelling
Contracting policies
Credentialing policies and procedures and NCQA
Microsoft Office software applications
Procedures and processes
URAC and CMS regulatory requirements
CMS credentialing requirements

Desired experience for credentialing representative includes:

Stays abreast of changing Joint Commission/ACR/State Department of Health and Customer credentialing requirements
Two years office experience or college course work preferred
Review reports (e.g., disciplinary reports
Contact primary sources, credentialing agencies, and/or reference on-line information sources in order to verify system of care provider credential information (e.g., licenses
Documents communication with system of care providers and/or administrative organization in the designated databases
Knowledge of industry terminology (e.g., medical

Credentialing Representative Examples

1

Credentialing Representative Job Description

Job Description Example
Our company is growing rapidly and is looking for a credentialing representative. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for credentialing representative
  • Making this kind of impact is no easy task
  • Credentialing of physical health providers and hospital privileging processes
  • Responsible for credentialing of physicians, allied health and other providers/practitioners
  • Review and research practitioner data, including both routine and exception credentialing and re-credentialing files, applying established decision matrix criteria when appropriate and effectively communicate exception findings as appropriate
  • Handle highly sensitive and confidential information regarding the practitioner networks and the credentialing/re-credentialing processes
  • Obtain updated practitioner information, as needed, from various sources
  • Inform/Educate practitioners and credentialing contact personnel of the submission requirements for the credentialing/re-credentialing process, stressing the importance of compliance with the processes
  • Performs accurate data entry of all practitioner/provider application data into the credentialing database and the document management database
  • Resolve any issues that arise with internal and external customers
  • Demonstrate great depth of knowledge/skills in own function and act as a technical resource to other
Qualifications for credentialing representative
  • Knowledge of credentialing procedures, policies, and terminology (e.g., NCQA
  • Requires up to 25% local San Diego travel to provider sites
  • Previous experience in managed care credentialing preferred
  • 3 - 5 years’ experience in human resources or technical credentialing administrative role required
  • Familiar with credentialing processes and certification boards
  • Job requires approximately 10% travel
2

Credentialing Representative Job Description

Job Description Example
Our company is growing rapidly and is looking to fill the role of credentialing representative. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for credentialing representative
  • Develop and oversee management of new and current internally created Processor Control Numbers and pre / post edits
  • Monitor, respond and ensure emails submitted to the Managed Care distribution email are addressed timely
  • Assist in monitoring and responding to Managed Care Trouble Tickets
  • Researching low cost claims, claims with reimbursement issues, claims that are requested to be rebilled
  • Assist in admin - rebills when necessary and approved by claim analysis supervisor
  • Successfully resolving reimbursement issues and communicating resolution
  • Maintain third - party contract database
  • Download, save and distribute Managed Care reports
  • Monitor plan, network and payer changes
  • Basic understanding of third - party contracts and payers
Qualifications for credentialing representative
  • Experience with Microsoft Word, Excel and PowerPoint with the ability to edit, create, save and send spreadsheets and documents
  • 5 years healthcare experience in an administrative role in a health system
  • College degree in business, communications or health care administration preferred
  • Experience in physician credentialing, enrollment and as a liaison with professional clients in the medical field
  • High School Diploma / GED (or higher) or equivalent experience
  • 1+ year of experience working with Microsoft Word (opening letters and entering information into fields, data entry) and MS Excel (opening documents, searching, sorting and capturing print screen data template data entry) and Adobe Acrobat (edit docs, merge docs, pdf conversion)
3

Credentialing Representative Job Description

Job Description Example
Our growing company is hiring for a credentialing representative. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for credentialing representative
  • Communicate claim issues, reimbursement changes or issues with appropriate account manager
  • Maintain understanding of NCPDP and NPPES
  • Monitor plan updates and changes
  • Analyze, rejected claim report and communicate necessary information on rejected claims by specific plan, network or contract
  • Maintain an understanding of Avella drug mix by pharmacy specifically specialty drugs and limited distribution drugs
  • Ensure and aid in communicating pharmacy issues related to contract are resolved timely and work closely with client to prevent future issues
  • Communicate reports, results, and proposals to internal executive staff
  • Maintain 100% accuracy of switching services including but not limited to internal Processor Control Numbers and pre / post edit
  • Process provider applications including mailing, reviewing against established criteria, primary source verifications, and loading into the SharePoint and database tracking systems
  • Notify providers of the credentialing review process outcomes, including options for reconsideration
Qualifications for credentialing representative
  • 1+ year of Health Care Provider or Home and Community Based Services Credentialing experience
  • 1 year experience in credentialing environment or in the health/managed care industry
  • Working knowledge and proficient in all Microsoft Office programs
  • Ability to deal with a diverse and challenging provider population
  • Ability to respond professionally when dealing with confrontational individuals and situations
  • Ability to work independently and to interact with all members of the credentialing team, both internal and external customers
4

Credentialing Representative Job Description

Job Description Example
Our growing company is looking to fill the role of credentialing representative. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for credentialing representative
  • Perform outreach via phone, fax and e-mail to obtain missing information needed to complete provider credentialing files
  • Track the status of receivables
  • Manage accounts payable and accounts receivable operations in compliance with company policies and procedures as assigned by a direct supervisor
  • Manage outstanding AP/AR issues
  • Prepare complex reports for management review on a routine basis
  • Mentor other staff by providing guidance and leadership with the assigned function(s) as applicable
  • Submits requests for all Medical Staff and Advanced Practice Provider applications
  • Assesses applications for completeness
  • Produce verification letters and evaluates if further investigation or information is necessary and makes appropriate inquiries
  • Works closely with practitioners and clinical department personnel to ensure that all applications are completed correctly and processed in a timely manner
Qualifications for credentialing representative
  • Ability to meet or exceed productivity standards established by management
  • Ability to work on a regular and timely basis which may require working irregular hours, holidays, and/or weekend
  • Strong interpersonal skills, the ability to multi-task, excellent organizational and planning skills, Excellent written and verbal communication skills and display a professional demeanor
  • Intermediate level of proficiency with MS Excel (working in spreadsheets) and Word (create and edit documents)Preferred Qualifications
  • Associates Degree (or higher) or equivalent of a minimum of 5 years’ experience in an equivalent full - time pharmacy or customer service related role
  • Licensed Pharmacist or Certified Pharmacy Technician
5

Credentialing Representative Job Description

Job Description Example
Our company is hiring for a credentialing representative. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for credentialing representative
  • Responsible for monitoring expirables
  • Responsible for managing all outside requests for practitioner hospital/facility verifications
  • Perform specific functions pertaining to the Medical Staff credentialing process as assigned
  • Assists in creating specialized reports and answers phones
  • Maintains filing (paper and electronic) on a consistent time schedule to ensure compliance with department process and regulatory standards
  • Maintains necessary knowledge regarding Optum policies, credentialing principles, regulatory/legal standards
  • Must have the ability to independently assist practitioners with credentialing and privileging process and questions
  • Manage protected information in a secure and confidential manner
  • Establish and maintain rapport with internal and external customers
  • Coordinates materials for monthly Credentials Committee Meetings and other meetings related to credentialing and privileging processes
Qualifications for credentialing representative
  • Basic understanding of pharmacy claims processing workflow, pharmacy management system, switching service and Pharmacy Benefit Manager processes
  • Skilled in Microsoft Excel on a basic level (ability to set up spreadsheets, sort and filter data)
  • Extensive knowledge and understanding of carrier codes and how they function within the pharmacy software system
  • Knowledge of managed care and specialty pharmacy industry and experience with client relationship building, negotiations, and budget management
  • Demonstrate ability to develop and manage relationships with management, co-workers and all Avella staff specifically related to pharmacy operations
  • Skilled in critical thinking, strong verbal and written communication, including presentation skills that is effective with all levels of management, teams, clients, and vendors

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