Credentialing Specialist Job Description
Credentialing specialist
provides applications to physicians, allied health professionals, and dependents; and enters this information into the credentialing software per credentialing policy.
Credentialing Specialist Duties & Responsibilities
To write an effective credentialing specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included credentialing specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Conduct initial credentialing application reviews and summarize results for Medical Director's review
Ensure compliance with National Committee for Quality Assurance (NCQA) credentialing standards
Complete the required number of credentialing files each day
Maintain provider database and ensure the timely and accurate submission of data and reporting for provider correspondence, the Plan's Information Services Department, Management Service Organization (MSO), and other appropriate usage
Act as liaison between the Plan and providers regarding credentialing and re-credentialing activities in consultation with the Medical Director
Maintain provider credentialing files in compliance with regulatory standards
Maintain current knowledge of regulatory requirements and standards with regard to credentialing
Schedule quarterly Credentialing Sub-committee meetings
Communicate changes to credentialed provider network and to appropriate departments/staff
Coordinates provider credentialing process to increase efficiency and ensures that payer (e.g.Cigna) credentialing deadlines are met
Credentialing Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Credentialing Specialist
List any licenses or certifications required by the position: CPCS, CPMSM, NAMSS, GLBA, FCRA, NCQA, SC, AHP, DPPA, CMSC
Education for Credentialing Specialist
Typically a job would require a certain level of education.
Employers hiring for the credentialing specialist job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Education, Associates, Business, Health Care, Healthcare, Medical, Management, Health, Communication, Technical
Skills for Credentialing Specialist
Desired skills for credentialing specialist include:
Health care and credentialing industry
National standards
Regulatory agencies
Medical terminology
NCQA credentialing standards
Credentialing regulatory and accreditation requirements
Credentialing software sufficient to develop appropriate reports on all aspects of credentialing
Medical/hospital/nursing profession
Excel
General office practices and software applications and database management
Desired experience for credentialing specialist includes:
Coordinates the receipt and review of completed provider applications while ensuring that facilities are in compliance with current standards
Collects and analyzes information submitted by providers for problems and/or conflicts (i.e., professional liability, licensing or quality issues) and assists manager in preparing Issue Summary for presentation to Credentialing Committee
Manages the collection of data related to provider credentialing and re-credentialing, contracting and performance
Develops with the Supervisor/Manager, Credentialing Committee agendas
Manages agreement dissemination and receipt process with resolution of language change requests with legal department input as necessary
Answer, research, resolve and document provider calls involving a wide range of issues utilizing multiple information systems
Credentialing Specialist Examples
1
Credentialing Specialist Job Description
Job Description Example
Our company is hiring for a credentialing specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for credentialing specialist
- Correct payments or denials if necessary and appropriate, in accordance with claim adjudication guidelines
- Diffuse irate callers by attentive listening, maintaining a professional tone, and acknowledging their concerns by paraphrasing
- Exercise good judgment, interpret medical claim data and contracts, and remain knowledgeable in related company policies and procedures
- Maintain teamwork, customer service production and quality standards to assure timely, efficient and accurate call resolution
- Maintaining compliance with regulatory and accrediting bodies
- Participating in the development and implementation of credentialing processes and procedures
- Credentialing of physicians and allied health professionals
- Collecting and maintaining an accurate practitioner database and analyzing verifications
- Credentialing physicians and allied health professionals
- Collecting and maintaining an accurate practitioner database
Qualifications for credentialing specialist
- Analyzing verifications
- Establishing and maintaining a system for timely processing of credentialing and re-credentialing files in accordance with the company, CMS and NCQA policies
- Ensuring that providers/HDOs on the company's participating panel are in compliance with the company policies and NCQA and state and federal regulatory standards
- Maintaining current knowledge of NCQA, State and Federal requirements
- Performing data entry in and maintaining currency of the database for tracking practitioner / HDO credentialing and re-credentialing information
- Initiating and conducting primary source verification of provider credentials
2
Credentialing Specialist Job Description
Job Description Example
Our innovative and growing company is hiring for a credentialing specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for credentialing specialist
- Assembling all verified information and prepares files for presentation to the Medical Director and/or the company's Quality Improvement Committee for approval or recommendation to not credential
- Maintaining communications with provider offices to promote relationships imperative to process
- Modifying and designing reports and queries to demonstrate the effectiveness of the credentialing / re-credentialing process
- Timely collection of credentialing and application information in provider files
- Credentialing new physicians as they are added to the network
- Reviewing all required documents to ensure compliance is necessary
- Builds file documentation and prepares file for credentialing committee review
- Applies general guidelines in determining whether provider meets criteria and documents deficiencies
- Communicate with Sales team or the customer any clarification items or additional compliance requirements needed that customer did not supply
- Make decision as to whether potential customer will pass our compliance requirements
Qualifications for credentialing specialist
- Minimum 2 years of college, or equivalent work experience
- Minimum 3 years of experience in credentialing or related field
- The ideal candidate will possess strong communication and interpersonal skills
- Must have a working knowledge of Microsoft Office, including Outlook and Word
- Previous Provider Enrollment experience OR experience on the Payer side of Insurance
- Healthcare industry/Payer side preferred
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Credentialing Specialist Job Description
Job Description Example
Our innovative and growing company is looking for a credentialing specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for credentialing specialist
- Use proprietary system “ACE” to record and document outcome of credentialing requirements
- Internal and External Customer Communication
- Contact potential customer for questions about their application or to request additional information for compliance review
- Keep sales team informed of potential customer’s compliance status
- Maintain minimum Production and Quality Control scores
- Support at least 1 business unit
- Conducts audits of eVIPs, confirming accurate input of provider data, including auditing other staff data entry and verifying accuracy of modifications made to the database
- Work with local teams to maintain appropriate logs of database-related problems and modifications
- Implement processes around credentialing/re-credentialing applications accurately and promptly in accordance with internal medical group policies and procedures and NCQA standards
- Obtains and validates CMS and State Surveys, State Licenses, Business Licenses, Medicare Certifications, Medicaid Certifications, CLIAs and Other Documentation as necessary
Qualifications for credentialing specialist
- Working knowledge of Credentialing software (Cactus, IntelliSoft, Vistar, Morrisey)
- Knowledge of credentialing or claims processing systems and guidelines
- Proficient personal computer skills to include electronic mail, record keeping, routine database activity, word processing, spreadsheet applications, graphics
- Ability to manage time sensitive and confidential documents
- Must be able to oversee other departments’ work is accurate and timely with a strong sense of urgency
- Ability to identify important issues and opportunity and report to supervisor
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Credentialing Specialist Job Description
Job Description Example
Our company is searching for experienced candidates for the position of credentialing specialist. 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 specialist
- Maintains Document Inventories and ensure accuracy and completeness
- Runs and manages weekly “Missing Documents Report” and follow up as needed
- Updates Encyclopedia continuously (where managed by DFC) to ensure information is current and complete
- Maintains working relationships with Regulatory Affairs, License & Certification and Facility Administrators
- Audits reports and document data sources to monitor accuracy/quality
- Enters current demographic information into ECHO including additions/deletions to the Medical Staff address/phone changes in an ongoing basis
- Maintain timely and accurate data entry and periodically revise practitioner data in the credentialing database
- Enroll practitioners with all appropriate client health plans
- Ensure all practitioners who require collaboration agreements are appropriately assigned to a collaborating physician and the agreement is executed by both parties
- Ensure employed practitioners are enrolled under the professional liability insurance plan
Qualifications for credentialing specialist
- Associates or Bachelor’s degree in health care related or similar field preferred
- Must possess ability to work efficiently with multiple applications and databases
- Ability to make informed decisions based on a specific set of guidelines
- Manual dexterity to operate PC’s and standard office machines
- Ability to communicate in person and on the telephone
- Demonstrated proficiency in Credentialing software, Cactus, IntelliSoft, Vistar, Morrisey
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Credentialing Specialist Job Description
Job Description Example
Our company is looking to fill the role of credentialing specialist. 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 specialist
- Adhere to policies and procedures including timely delivery of completed work and use of resources
- Monitor work queue to ensure that applications are processed within a 30-day turn around time
- Performs and oversees hospital credentialing process for all providers at contracted facilities
- Adheres to internal and contracted facility procedures of credentials verifications
- Maintains credentialing database
- Work with practitioners to ensure timely and thorough completion of applications, in compliance with TJC and NCQA standards
- Assists team members with questions regarding processing of files, problem solving, and managing files with identified concerns
- Identify and assist with developing improvement in processes
- Provide training and orientation to new employees
- Assist in maintaining department databases, performance improvement processes
Qualifications for credentialing specialist
- Demonstrated proficiency in credentialing software, Cactus, IntelliSoft, Vistar, Morrisey, etc
- Strong knowledge of managed care systems and contract related activities including
- Maintains strict confidence of client information, ensuring client's privacy
- Minimum of six (6) months’ administrative or clerical business office experience required
- Minimum of six (6) months’ experience in licensing, healthcare, or insurance strongly preferred
- Certification or training in related area strongly preferred