Credentialing Specialist Resume Samples

4.9 (81 votes) for Credentialing Specialist Resume Samples

The Guide To Resume Tailoring

Guide the recruiter to the conclusion that you are the best candidate for the credentialing specialist job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.

Craft your perfect resume by picking job responsibilities written by professional recruiters

Pick from the thousands of curated job responsibilities used by the leading companies

Tailor your resume & cover letter with wording that best fits for each job you apply

Resume Builder

Create a Resume in Minutes with Professional Resume Templates

Resume Builder
CHOOSE THE BEST TEMPLATE - Choose from 15 Leading Templates. No need to think about design details.
USE PRE-WRITTEN BULLET POINTS - Select from thousands of pre-written bullet points.
SAVE YOUR DOCUMENTS IN PDF FILES - Instantly download in PDF format or share a custom link.

Resume Builder

Create a Resume in Minutes with Professional Resume Templates

Create a Resume in Minutes
CH
C Hansen
Cora
Hansen
2691 Stamm Motorway
Chicago
IL
+1 (555) 404 3351
2691 Stamm Motorway
Chicago
IL
Phone
p +1 (555) 404 3351
Experience Experience
12/2014 present
New York, NY
Provider Enrollment Credentialing Specialist
New York, NY
Provider Enrollment Credentialing Specialist
12/2014 present
New York, NY
Provider Enrollment Credentialing Specialist
12/2014 present
  • Perform ongoing research to correct data so it does not create duplicate provider, locations, payees, and participation
  • Keep up to date provider enrollment process and records and track provider participation levels
  • Facilitate provider related research based on suspended claims, PO returns and other feedback opportunities
  • Maintain fee schedules by creating, reviewing and auditing provider fees
  • Review National Practitioners Data Bank for adverse charges pending or filed against Provider
  • Assist with other duties as assigned
  • Enter and maintain Provider applications, contracts and updates into the system
09/2007 06/2014
Boston, MA
Associate Credentialing Specialist
Boston, MA
Associate Credentialing Specialist
09/2007 06/2014
Boston, MA
Associate Credentialing Specialist
09/2007 06/2014
  • Assist in goals and performance standards management
  • Create and maintain provider files in compliance with the organization’s policies
  • Improve efficiencies and service provided while reducing costs
  • Assist with various projects as assigned by direct supervisor
  • Attend trainings and reference materials including content, work instructions, and tools
  • Abide by all policies, procedures, and work instructions for the credentialing function of the Medicare Advantage plan
  • Perform quality checks
03/2002 05/2007
Boston, MA
Credentialing Specialist
Boston, MA
Credentialing Specialist
03/2002 05/2007
Boston, MA
Credentialing Specialist
03/2002 05/2007
  • Accurately enter information into Network Connect (NWC) for all potential network providers and/or existing providers being re-credentialed for the network
  • Works with Network Management team, study managers and regulatory personnel to achieve goals for quality assurance and compliance
  • Works with Network Contracting and Provider Relations departments and other Beacon staff to ensure follow up with providers when applications are incomplete
  • Works with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete
  • May assist in provider education and preparation of provider training materials
  • Act as project leader and assist in the development of provider data reporting, as requested
  • Perform delegated Credentialing duties as assigned by the Network Manager and according to existing
Education Education
Bachelor’s Degree in Business
Bachelor’s Degree in Business
University of Georgia
Bachelor’s Degree in Business
Skills Skills
  • Acquires and maintains knowledge of relevant product offerings, current support policies, and methods of support delivery, in order to provide technically accurate solutions to users
  • Researches, resolves, and responds to end-user/problems/questions received via email, telephone calls, callbacks, web requests or escalations, and provides support on technology platforms, in accordance with current standards and service levels
  • Coordinates user and support issues among corporate site and remote office locations to ensure timely distribution of knowledge and positive impact on user satisfaction and productivity
  • Great interpersonal skills
  • Excellent communication skills (written and verbal)
  • Strong attention to detail
  • Highly organized
  • Able to multitask efficiently and effectively
  • Ability to prioritize and complete projects within deadlines
  • Strong organizational, analytical, detailed-oriented, and interpersonal skills
Create a Resume in Minutes

15 Credentialing Specialist resume templates

1

Credentialing Specialist Resume Examples & Samples

  • Our Department of Defense contract requires U.S. Citizenship
  • Working knowledge of computers, or a demonstrated technical aptitude and and ability to quickly learn new systems
  • Associate’s or Bachelor’s Degree in a healthcare field or related field
  • Two years experience in provider relations, customer service in healthcare field or credentialing
2

Credentialing Specialist Resume Examples & Samples

  • Associate's Degree in healthcare administration, business or an equivalent combination of education and related work experience in managed care or healthcare
  • 1+ year of experience in provider credentialing
  • Strong organizational, analytical, detailed-oriented, and interpersonal skills
  • Knowledge of provider databases programs
3

Credentialing Specialist Resume Examples & Samples

  • Proficiency with Microsoft Office Word and Excel
  • Must have excellent time management and communication skills
  • Working knowledge of APEX and/or Singlepoint
  • Prior experience with credentialing
4

Credentialing Specialist Resume Examples & Samples

  • 1+ year of Credentialing experience
  • Proficiency with Credentialing software (Cactus, IntelliSoft, Vistar, Morrisey, etc.)
  • Knowledge of Hospital functions and Medical terminology
  • 5+ years of Hospital Credentialing experience
  • College Degree
5

Credentialing Specialist Resume Examples & Samples

  • Be responsible for credentialing and re-credentialing of all providers through primary source verifications (e.g. OIG, GSA/SAMS, NPDB, Boards, AMA, National Student Clearinghouse, various licensing agencies MSO and Medical Internship, Residency and Fellowship schools)
  • Maintain providers file with updated information
  • Follow up with clinicians/vendors and the staffing department for missing information, monthly tracking of expired licenses; scanning and indexing
  • Audit and submit files to Credentialing Manager for approval
  • Respond to all queries/questions from Staffing Department, Credentialing Committee, Director of operations and the different management teams
  • Completing special projects as assigned
  • 1 year Credentialing Experience
  • 2 years Healthcare Experience
  • Associate’s or Bachelor’s Degree in Business, Finance or a related field Reporting Relationships
6

Credentialing Specialist Resume Examples & Samples

  • Check provider applications on initial/recred credentialing for completeness and accuracy and follow-up, obtaining missing elements as necessary, including PLI exceptions and hospital waivers
  • Intervene as necessary to resolve issues involving unusual cases and processes, responding to field staff, provider office associates, Network Development, etc…
  • Supports the Credentialing Committee process
  • Timely and accurate completes primary source verification (PSV) of credentialing data in the Humana Government Business credentialing system (CVS)
  • Associates or Bachelor’s degree in health care related or similar field preferred. May substitute equivalent education and/or experience for degree
  • Proficiency in the MS Office Programs including Word, Excel, and Access or similar PC based applications required
  • Good written and verbal communication skills required
  • Our Department of Defense Contract requires U.S. citizenship for this position
  • Two years’ experience in provider relations, customer service in healthcare, or credentialing preferred
  • Knowledge of URAC Credentialing standards preferred
7

Credentialing Specialist Resume Examples & Samples

  • 1-2 years of credentialing experience
  • Demonstrated proficiency in data entry, Microsoft Word and Excel
  • Demonstrated proficiency in credentialing software
  • Knowledge of hospital functions and medical terminology
  • 5 years of hospital credentialing experience
8

Credentialing Specialist Resume Examples & Samples

  • 2+ years of previous experience in a Health Insurance environment, preferably in provider relations or credentialing
  • Associate's Degree or an equivalent combination of education and experience
  • Working knowledge of Amisys Advanced
  • Solid knowledge of Medical terminology
  • Experience in Provider Relations or Credentialing
  • Knowledge of NCQA and CMS requirements
9

Credentialing Specialist Resume Examples & Samples

  • 1 year of previous medical staff credentialing experience
  • Demonstrated knowledge of credentialing procedures, policies and terminology
  • Strong proficiency in Microsoft Office Suite
10

Credentialing Specialist Resume Examples & Samples

  • Maintain electronic files that meet all regulatory agencies
  • Serve as the person responsible for processing credentials files that contain dated accurate approved content on time, verify a professional history, communicate the status directly to providers and administrators and meet regulations
  • Monitor all aspects of the file process and evaluate for a total picture of the physician’s background
11

Credentialing Specialist Resume Examples & Samples

  • 1-3 years credentialing or related experience; or any combination of education and experience, which would provide an equivalent background
  • Excellent computer skills, including word processing, spreadsheet and database management software
  • Strong oral and written communication and research/problem solving skills
  • Experience/knowledge with NCQA standards
12

Credentialing Specialist Resume Examples & Samples

  • Receives provider applications and contacts providers for any additional supporting documentation or clarification
  • Builds file documentation and prepares file for credentialing committee review. Applies general guidelines in determining whether provider meets criteria and documents deficiencies
  • Prepares correspondence to providers regarding status
  • Assists in researching pended and probated applications and resolving discrepancies
  • Refers non-approved providers or questionable situations to senior representative
  • May assist in provider education and preparation of provider training materials
13

Credentialing Specialist Resume Examples & Samples

  • Processes initial and reappointment credentialing applications as assigned
  • Effective data entry of documentation from initial and reappointment applications
  • Conducts follow up of outstanding information and verifications in a timely and effective manner in alignment with CVO processing guidelines
  • Conducts audits of initial and reappointment credentials files as assigned
  • Responsible for meeting set performance goals with regard to quality and accuracy of work
  • Manages and prioritizes assigned work so that turnaround time goals are met, in process files are kept up-to-date, and assigned files are processed in a timely manner
  • Performs related and unrelated tasks as assigned
  • Ability to work collaboratively and train others
  • Knowledge of hospital credentialing and privileging preferred
  • Knowledge of CACTUS Credentialing System desired
  • Healthcare insurance experience preferred
  • Payer enrollment experience preferred
14

Credentialing Specialist Resume Examples & Samples

  • Associate’s degree or equivalent preferred but not required (i.e. some college)
  • Requires 1-3 years of experience in health care credentialing/ verification
  • Knowledge of Health Line System (Medical Staff Line and/or Echo) or other credentialing system preferred
  • Knowledge of basic anatomy and physiology, medical terminology and functions of medical staff services
  • Advanced computer skills in word processing, spread sheets and databases
15

Credentialing Specialist Resume Examples & Samples

  • Recent experience is deemed to be within the last five (5) years
  • Medical Staff Services Office provides credentialing to medical practitioners to ensure they meet the standard requirements that are necessary for them to perform their medical duties
  • *Experience at the level of Intermediate Typist Clerk in the County of Los Angeles is defined as: Positions allocable to this class, in addition to performing skilled typing work, perform specialized clerical duties requiring a working knowledge of specialized subject matter and the specialized clerical functions involved and the use of initiative and judgment with procedural and policy limits
16

Credentialing Specialist Resume Examples & Samples

  • A minimum of three years' experience in a medical staff office or healthcare administration required
  • Knowledge of applicable JCAHO and NCQA standards as well as Federal and State regulations
  • Two (2) + years of college preferred
  • Five (5) + years working with a variety of healthcare providers preferred
  • Excellent oral and written communication skills; attention to detail;strong planning and organizational skills; ability to evaluate and prioritize; ability to meet critical time deadlines; ability to work under stress; ability to initiate and follow-through independently; decision-making, problem-solving and judgment skills; computer database skills and software application programs (Microsoft Office); ability to utilize and understand medical terminology
  • Must maintain confidentiality of information
17

Senior Non-delegated Credentialing Specialist Resume Examples & Samples

  • Coordinate and expedite document flow in the development and completion of applications in a timely manner to include interfacing with payer; the applicant; to ensure timely compliance with all applicable standards including but not limited to NCQA and URAC
  • Serve and primary trainer for customer practices concerning the submission and maintenance of credentialing data
  • Submit reports to management concerning the status of assigned applications
  • Assume the duties of Non-Delegated Credentialing Manager in their absence
  • Mastery of the credentialing application process with commercial carriers and government programs
  • Five (5) years’ experience in health care with a payer, physician practice, and/or working in a facility in the hospital privileges or managed care function
  • Demonstrated experience in customer service and handling highly sensitive medical information
18

Credentialing Specialist Resume Examples & Samples

  • Processes both initial and re-credentialing applications in accordance with bylaws, policies and procedures for presentation to Credentialing Committee
  • Provides information to other MHS staff members allowing maintenance of both payer files and directories
  • Serves as “back-up” for MHS staff involved in claims resolution for providers and payer relations
19

Credentialing Specialist Resume Examples & Samples

  • Minimum experience of six (6) years as executive/legal and three (3) years in a Medical Staff Office in a hospital setting
  • Able to take minutes
  • Demonstrates computer literacy knowledge of Word, Excel, Access, etc
  • High energy necessary, must be able to handle multi-tasks
  • Must be able and have transportation between facilities
  • (CPCS) Certification Provider Credentialing Specialist Certification desired
20

Credentialing Specialist Resume Examples & Samples

  • Manage the process of sending initial and/or reappointment applications and monitoring their return with required documents
  • Responsible for processing appointment/reappointment applications in an accurate, thorough, and timely manner; clearly and succinctly communicate reappointment status to applicant in writing
  • File appointment/reappointment applications and other communication as needed
  • Prepare files other documents, as requested, for review and evaluation of the clinical Service Chief and Credentials Committee in an accurate, consistent, professional, and organized manner
  • Perform 3rd party verifications of submitted material as required by department policy, medical staff policy, and the Bylaws of the Medical Staff
  • Document receipt of application materials and verifications in the credentialing system (ECHO) (e.g. Texas Medical License, Malpractice Insurance, DEA, Board Certification, DPS, etc.). File copy in physician's file
  • Ensure all credentialing-related information is accurate and up to date in the ECHO system and in the applicant files
  • With the assistance of the Supervisor, utilize Echo to run reports and make certain all certifications and other tracked information as required is up to date and accurate
  • Proficiency in Word and Excel
  • Excellent data entry skills
  • Knowledge and usage of office equipment (i.e. printer, copier, fax machine, scanner)
  • Previous Medical Staff Credentialing experience
21

Client Credentialing Specialist Resume Examples & Samples

  • Works under limited supervision and is competent to perform most aspects of the job independently
  • Follows guidelines and procedures
  • Errors may result in the company being out of compliance with credit repositories and/or regulatory entities
  • Proficient in Microsoft Office Products, Word, Excel and Outlook
  • HS Diploma/GED required; some college preferred
  • Intermediate knowledge of Microsoft Office products is preferred
  • Entry Level Position. On the job training provided
22

Credentialing Specialist Resume Examples & Samples

  • 1-2 years working experience in a healthcare administrative support position
  • Credentialing certification from a nationally recognized organization is preferred
  • Must meet satisfactory completion of all training and testing: Data Entry 9000 KPH, Correspondence test, CRM Navigation
  • Ability to multitask in fast paced environment
  • Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills
  • Proficiency in English language skills including spelling punctuation and grammar in both written and verbal communication to ensure communications are issued in a professional manner
  • Ability to effectively communicate in both written and verbal communication with internal and external contacts in a professional manner
  • Working knowledge of personal computer and application software such as Microsoft Office
  • Computer Software typically used: Microsoft Office, Facets, Internet
23

Credentialing Specialist Resume Examples & Samples

  • Must be able to work in a team oriented environment
  • Working knowledge of Microsoft Word and Excel
  • CAQH experience preferred but not required
24

Credentialing Specialist Resume Examples & Samples

  • Obtains, verifies and maintains necessary practitioner credentialing/re-credentialing, demographic, and industry and regulatory body driven information
  • Performs credentialing/recredentialng activities and data entry into the credentialing database to meet established deadlines and ensure quality of data and integrity of information for presentation to the Credentialing Committee, submission on monthly rosters and reports
  • Follows the messenger model process, as needed, for independent community practitioners
  • Credentials and recredentials practitioners and providers directly contracted for the Cleveland Clinic Employee Health Plan
  • Develops, prepares and distributes standard and ad hoc reports in accordance with established schedules and requests
  • Completes credentialing and recredentialing applications for contracted health plans for all CCHS owned facilities to maintain revenue stream
  • Completes health plan enrollment activities for non-delegated plans
  • Applies for and maintains clinical privileges for CC practitioners at Nevada hospitals
  • Updates Council for Affordable Quality Health Care (CAQH) applications as needed
  • Completes Medicare, Medicaid and BWC validations and revalidations as needed
  • Completes health plan directory audits to comply with CCF initiatives, CMS and NCQA requirements as needed
  • Researches and resolves practitioner loading and claims issues for employed and independent practitioners with contracted health plans
  • Performs administrative tasks to support the initiatives of the Quality Alliance to include, entry and updating of new and existing Quality Alliance practitioners into Salesforce, reconciliation and auditing of reports and rosters to ensure networks are accurate and complete, collection of data regarding practice management systems, electronic funds transfer, and follow up with health plans regarding incentive payments and other provider inquiries
  • Collects and maintains agreements for Quality Alliance providers, including Quality Alliance participation and ACO (Accountable Care Organization) agreements
  • Reconciles verbiage in agreements with CMS data and requests new agreements as needed to comply with CMS reporting requirements
  • Assists in preparation of ACO submission lists
  • Minimum of three years of experience in hospital, managed care organization, health plan, network management or provider relations working with multi-specialty groups or other integrated delivery systems
25

Temporary Dental Credentialing Specialist Resume Examples & Samples

  • The position will collect and maintain up-to-date files in relation to credentialing including applications, contracts, licenses, DEA licenses, NPI numbers and other pertinent information
  • Prepares, submits and tracks insurance credentialing applications. Prioritizes and resolves inquiries on a timely basis
  • Reviews practitioners’ credentials to ensure that they are up-to-date. Accurate completion of forms, obtaining the practitioner’s signature, making file copies, and sending documentation to the appropriate facilities
  • This position should have the ability to search and maintain (as applicable) external websites for credentialing related information including, but not limited to, CAQH, PECOS, and NC Tracks
  • Position will communicate with providers and Patient Business Services staff members when necessary in a professional and courteous manner. Obtains verifications, performs data entry, accurately proofreads own work, maintains confidentiality, analyze data and make recommendation to supervisor, performs research and gathers data from multiple sources
  • Maintains the credentialing database. Scans credentialing verification information into appropriate practitioner folders
  • Monitors changing insurance credentialing rules/regulations. Ensures that all practitioners are in compliance with same
  • Completes all other duties as assigned
  • Associate’s degree is required. A combination of education and experience will be considered
  • Have clear and concise phone and verbal communication skills. Ability to write legibly
  • Demonstrate effective written communication skills
  • Have strong computer, typing, and data entry skills: includes MS Word, Excel and web-based applications, internet, and database programs
  • Detail oriented with ability to recognize vital information from verification documents
  • Possess proof-reading skills sufficient for auditing documents
  • Ability to prioritize well and meet overlapping deadlines
  • Demonstrate problem-solving, critical thinking, and deductive reasoning skills
  • Ability to consistently maintain quality and production expectations
26

Credentialing Specialist Resume Examples & Samples

  • Support assessment and evaluations of CDO credentialing capabilities to ensure national standards and guidelines are met for delegated credentialing
  • Work in conjunction with Credentialing and Contracting Implementation team to ensure workflows implemented support utilization of eVIPs
  • 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. Monitor security of data within the eVIPs with individuals to whom data or system access may be given; report infractions to the Associate Director
  • Maintain current knowledge of computer hardware and database software capabilities
  • Orient new staff to appropriate database use, capabilities, security, etc
  • Act as project leader and assists in the development of provider data reporting, as requested. Collaborate with Information Technology to review approved software installs, upgrades, incremental backups and restorations; assist in the development of configuration documentation and updates as necessary
  • Work with local teams to maintain appropriate logs of database-related problems and modifications; monitor database performance and space; investigate and resolve all departmental problems, questions and concerns, and make modifications, as necessary
  • Disseminate new / modified professional information to HMOs and to CDOs through the Information System Change Control Process
  • Implement processes around credentialing/re-credentialing applications accurately and promptly in accordance with internal medical group policies and procedures and NCQA standards. Provide guidance on the coordination of the credentialing and re-credentialing processes with the Quality Improvement Department and other internal departments, as necessary
  • Accepts and performs other duties and responsibility as assigned
  • 4 year college degree, health care related field preferred or equivalent work experience
  • 2+ years of experience in credentialing, preferably in a managed care setting
  • Must be eligible to take the National Association Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist exam within the first 18 months of employment
  • Must be a team player with excellent communication skills, both written and verbal
  • Strong organization and administrative skills, attention to detail and the ability to follow through
  • Must be able to prioritize many tasks and exhibit excellent, mature judgment
  • Excellent writing skills and attention to detail
  • Complies with company and departmental administrative policies and procedures; performs job safely with respect to others and to property
  • Maintains strict confidence of client information, ensuring client's privacy; and does not discuss internal business with external entities
  • Knowledge of Practice Management Software and Intellisoft Software System
27

Credentialing Specialist Lead Resume Examples & Samples

  • Requires a BA/BS degree in a related field
  • 5-7 years credentialing experience; or any combination of education and experience, which would provide an equivalent background
  • Certification preferred
  • NCQA knowledge required
  • Experience leading credentialing initiatives and projects
  • NCQA audit experience preferred
28

Corp Credentialing Specialist Resume Examples & Samples

  • Education: High school graduate, Associates Degree preferred
  • Experience: 6 months experience with a high school diploma in a credentialing or medical staff office setting, and privilege research or 0 months experience with an Associate's Degree in a Healthcare related field Licensure: CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Staff Management) Certification through NAMSS preferred
  • Skills & Abilities: Excellent interpersonal, communication and administrative skills; possess self-motivation, analytical and organizational skills; including basic record keeping, typing, computer website usage, filing practices, written/oral communication skills, ability to initiate inquires and follow-up with minimal supervision; work in a stress-filled, fast-paced environment to meet stringent timelines and ongoing deadlines; strong knowledge of Word, Excel, Access and credentialing database systems as well as JCAHO, NCQA, Federal and State standards and regulations regarding medical staff services
29

Credentialing Specialist Resume Examples & Samples

  • Differentiates manner of care, communication, and service to maximize effectiveness with age specific population
  • Ensures that all credentialing and re-credentialing of Medical Staff and Allied Health Professionals (AHP) applications are processed in compliance with Medical Staff Bylaws and Rules and Regulations
  • Processes credentialing files of Physicians/AHP's consisting of verifying education and training, licenses, board certification or eligibility, National Practitioner Data Bank, peer references, malpractice insurance & hospital affiliations
  • Knowledge of Medical Staff policy and procedures, JCAHO standards and other regulatory agency requirements
  • Maintains confidentiality of privileged information
  • Assure reappointment files are complete prior to being reviewed by the appropriate chairmen
  • Enters current demographic information into ECHO including additions/deletions to the Medical Staff as well as address/phone changes in an ongoing basis
  • Maintains expired licensures including: license, DEA, DPS and malpractice insurance (on-going)
  • Receives and records Medical Staff/Allied Health application fees
  • Responds to queries from other hospitals/institutions regarding Practitioners membership verifications
  • Receives, reads and sorts all incoming mail for the department
  • Maintains efficient and comprehensive working knowledge of the office software, including but not limited to, physician profile software
  • Ensures filing is maintained in a current and accurate manner
  • Assists the Director of Medical Staff with call schedules, meeting preparation and special projects when requested
30

Credentialing Specialist Resume Examples & Samples

  • Knowledge and usage of office equipment
  • Prepare files other documents, as requested, for review in an accurate, consistent, professional, and organized manner
  • Perform 3rd party verifications of submitted material as required by IPA Policies and Procedures
  • Document receipt of application materials and verifications in the credentialing system (Morrisey) (e.g. Texas Medical License, Malpractice Insurance, DEA, Board Certification, DPS, etc.). File copy in physician's file
  • Utilize Morrisey to run reports and make certain all certifications and other tracked information as required is up to date and accurate
31

Credentialing Specialist Resume Examples & Samples

  • At least 1 year of physician or ancillary/long term care credentialing preferred
  • At least 1 year of experience medical field preferred
  • Strong written and oral communication skills required
  • Must be able to work in a fast paced production environment
32

Credentialing Specialist Resume Examples & Samples

  • Gather all necessary Licensure and other Practitioner background items
  • Enter, maintain and update credentialing software program (OneAPP)
  • Enter, maintain and update Practitioners credentialing data storage drive
  • Process Credentialing to contracted insurances/networks for newly hired group Practitioners and ReCredentialing for existing group Practitioners as required
  • Process Credentialing to inpatient facilities (i.e. Hospitals/SNFs/Surgery Centers, etc.) for newly hired group Practitioners and ReCredentialing for existing group Practitioners as required
  • Conduct continuous compliance audits of existing Practitioners to maintain proper documentation
  • Perform primary and secondary source verifications of Practitioner’s credentials according to policy
  • Update appropriate outside Credentialing databases and websites as necessary to ensure information is current and accurate
  • Perform all other duties as assigned by Management
  • 2 Years minimum Credentialing experience including Hospitals/SNFs/Surgery Centers
33

Provider Credentialing Specialist Resume Examples & Samples

  • Bachelor's Degree preferred or equivalent courses, training and experience, required
  • Strong computer and information management skills required
  • One to three years experience in a medical credentialing or provider enrollment environment (payer, IPA, managed care organization, medical group or institutional privileging) preferred
  • Knowledge of NCQA, physician payer credentialing, physician and allied provider privileging, and/or physician/provider and site regulatory licensing a plus
  • Prior experience with Managed Care Organizations, Centers for Medicare and Medi-Cal enrollment preferred
  • CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) preferred
  • Understand Medicare, Medicaid and commercial payer application process and EDI agreements
  • Fully proficient in online credentialing applications, such as CAQH, Pecos, NPDB, OIG, and AMA's profile service
34

CSS Credentialing Specialist Resume Examples & Samples

  • Perform primary (e.g., hospitals, licensing boards, etc.) and secondary source verifications of perspective providers' credentials with special emphasis on provider issues relating to malpractice claims, privileging, criminal concerns, license anomalies and discrepancies in education
  • Responsible for gathering and verifying physician information, compiling required documents, researching necessary information and verifying medical licenses
  • Compiles documents, researches and verifies provider backgrounds by contacting hospitals, licensing boards, medical schools, etc
  • Contacts or interviews provider peer references over the phone about the providers clinical performance skills
  • A minimum of 0-2 years’ experience in data entry, office administration management or medical financial experience. 0-2 years’ experience in credentialing/licensure verification/checks. Home health experience preferred. Requires excellent analytical skills, flexibility and ability to perform detailed follow through and prioritization
35

Credentialing Specialist Resume Examples & Samples

  • Perform the initial credentialing and recredentialing functions for employed and contracted practitioners, which may include collaborating physicians, Locum Tenens, nurse practitioners, registered nurses and social workers
  • Maintain timely and accurate data entry and periodically revise practitioner data in the credentialing database; maintain practitioner paper and electronic data files for practitioners; use the CAQH system to submit practitioner data as required by some client health plans to credential individual practitioners
  • Enroll practitioners with all appropriate client health plans; monitor and report on progress of each practitioner
  • Ensure all practitioners who require collaboration agreements are appropriately assigned to a collaborating physician and the agreement is executed by both parties; monitor and report progress of each practitioner
  • Ensure employed practitioners are enrolled under the professional liability insurance plan; monitor and report progress on each practitioner
  • Monitor expiring licensure, board and professional certifications and other expirable documents with practitioners within the prescribed time frames as outlined in the policies and procedures, assisting practitioners with timely renewal as appropriate and escalating to manager and field management as appropriate
  • Conduct sanctions and compliance monitoring and alert Manager of any undisclosed negative findings immediately
  • Assist traveling practitioners with obtaining new state licenses in areas identified by the clinical management team; monitor and report progress of each practitioner
  • Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services rendered; discover and convey problems to Manager
36

Credentialing Specialist Resume Examples & Samples

  • Execute licensure and credentialing processes for new and existing providers including but not limited to obtaining or requesting required documentation from various third-party sources and regular communication with appropriate state board representatives and the Field Management Team
  • Source and maintain up-to-date information regarding all new and existing state and federal requirements as they pertain to professional licensing and credentialing requirements, processes, schedules, etc
  • Report licensure and credentialing expiration dates and renewal requirements to the providers as well as the appropriate members of the Field Operations Management Team, Compliance & Risk Management, etc
37

MSN Credentialing Specialist Resume Examples & Samples

  • Building/maintaining relationships with field/branch employees
  • Accurate completion of employee files including pre-employment screenings, credentialing, and testing
  • Managing compliance in accordance with Joint Commission and MSN standards
  • Working with existing field/branch employees to keep documents current, active and compliant
  • Providing back-up support (with additional functions as deemed required) to help assure all operational needs are met
  • Computer proficient including Microsoft Office programs
  • Possesses capable, efficient customer service, organizational and human relations skills, along with the ability to create a sense of urgency to help expedite results
  • Knowledge of the medical/hospital/nursing profession a plus
  • High school diploma required; some college preferred
  • Two (2) years HR and or credentialing background preferred
38

Credentialing Specialist Resume Examples & Samples

  • Performs analysis and appropriate follow-up. Works with many individuals to acquire necessary materials and information, including, but not limited to: physicians, facility staff, professional staff and physicians office staff
  • Performs relevant data entry into the database to ensure consistency and integrity of the data
  • Processes appropriate queries for expired licensure, or any appropriate regulatory credentialing requirement and maintains documentation in the database
39

Credentialing Specialist Resume Examples & Samples

  • Possess thorough knowledge and full compliance with ValueOptions a Beacon Health Options Company and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations. Maintain strict confidentiality of member and provider information
  • Possess thorough knowledge of all facility program types commercially contracted by ValueOptions a Beacon Health Options Company to include full validation of compliance with clinical and credentialing criteria for such programs
  • Perform verbal, written, and on line verification of credentials including but not limited to medical experience, state licensure, prescribing certificates, education, modality, age ranges treated, accreditation status, Medicare/Medicaid certification, programs name/ address/ intake phone number, staff roster information, and (written) validation of program no longer offered
  • Prepare files for presentation to the National Credentialing Committee for approval, denial or recommendation for termination
  • Monitor work queue to ensure that applications are processed within a 30-day turn around time. Record and report work volume. Maintain production levels and quality scores in accordance with set standards for a Credentialing Specialist Level I specializing in Credentialing Review and Primary Source Verification Review
  • Manage and maintain the integrity of the provider credentialing database including data entry of credentialing information which requires full comprehensive and application of all applicable proprietary software applications (Connect products) in addition to utilization of multiple job aids and/or Access databases
40

Credentialing Specialist Resume Examples & Samples

  • Credentials and re-credential behavioral health providers using Cactus credentialing database
  • Works with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete
  • Performs primary source verification for individual credentialing & confirmation of facility accreditation and licensure
  • Tracks the recredentialing cycle of provider’s credentialing. Prepares files for monthly Credentialing Committee
  • Knowledgeable of current NCQA, CMS, DHCS, DMHC and other regulatory body’s credentialing standards
  • Previous data entry required. Microsoft Word, Excel, Outlook and Powerpoint experience required
  • Self-motivated, able to prioritize multiple assignments, excellent organizational skills, ability to track multiple projects/tasks and follow through as needed
41

Credentialing Specialist Resume Examples & Samples

  • Performs and oversees hospital credentialing process for all providers at contracted facilities. Primary contact for medical staff offices of assigned sites. Initiates process of credentialing at client hospitals (requesting application) and follows through on entire process to ensure providers obtain privileges prior to working their first shift. This involves reviewing files to ensure application is completed correctly and that the proper documentation is provided to client hospital, following up with client hospital medical staff office and providing assistance to resolve issues in order to facilitate the credentialing process
  • Adheres to internal and contracted facility procedures of credentials verifications (I.e. license & data bank queries)
  • Initiates obtaining professional liability insurance certificates for providers
  • Maintains credentialing database; performs all required data entry to ensure the completeness and accuracy of the database, responsible for ensuring all credentials on file are current and that copies have been provided to client hospital. Includes running monthly credentialing expiration reports that notify providers of documents that have expirations that are pending
  • Provides status reports on pending providers
  • Keeping up to date with rules and regulations with various licensing agencies to ensure compliance
  • Maintains highest level of confidentiality related to provider issues in performing the above tasks
  • Performs other related duties as required and assigned
42

Credentialing Specialist Resume Examples & Samples

  • Adhering to established credentialing guidelines completes in-depth review and analysis of practitioner’s application and accompanying documents ensuring applicant meets facility guidelines and eligibility. Examines researches, enters data, sets up files and gathers all information necessary to process information received from providers to support and complete the initial, reappointment and expirable credentialing process. Utilizes various websites, contacts educational facilities and professional references to verify credentials. Ensures compliance with facility Medical Staff Bylaws, Rules and Regulations, policies and procedures for hospital clients and EmCare
  • Extensive and frequent verbal and written communications with Clinicians, Medical Staff Offices, educational facility, state licensing boards, professional references and internal company staff, requiring professionalism and tact, to attain or provide all needed information quickly in order to expedite the credentialing of Clinicians. Provides excellent customer service in accordance with EmCare’s customer service standards to all internal and external parties
  • Achieves compliance with Credentialing Department metrics and performance standards by adhering to the Credentialing process and documenting accurately in company databases. Accurately maintains systems data bases and spreadsheets to track, follow-up and disseminate hospital privilege status to other department in a timely manner. May be involved in generating and managing various reports for management, implementing best practices and working on projects as assigned
  • Attend and participate in all team related meetings; participating in developing and implementing company-wide and team goals; participates in problem-solving and decision making; positively supports and adheres to corporate and division management decisions, being flexible and adaptable to change, establishing trust and respect for other team members and completing training as required
  • Credentialing experience preferred, but will train the right individual
  • Knowledge of related credentialing, privileging, accreditation and certification procedures, requirements and hospital operations preferred
  • Experience with State and Regulatory agency requirements as it relates to healthcare credentialing guidelines preferred
  • Excellent verbal and written communication skills are essential. Able to communicate and present information to a wide variety of parties effectively
43

Credentialing Specialist Resume Examples & Samples

  • A comprehensive benefits package
  • A clear career path with opportunities for advancement
  • A supportive, fun, team environment
44

Credentialing Specialist Resume Examples & Samples

  • File Preparation
  • As a member of an integrated team, open and process practitioner credential, quality, provider assessment files in compliance with KPNW Credentialing and Recredentialing Policies and Procedures and QRM desk procedures. Communicate effectively with NWP and KFHP to obtain human resources and provider contract information as inputs to the credentialing and assessment processes. Mail credentialing application packets to applicants and follow-up, as needed. Investigate record of previous KPNW credentialing. Assure paper file in standardized order. Maintain electronic file record accurately, timely, with agreed formats for style, case, and professional language. Assess need for delineation of privileges; facilitate applicant and chief to achieve accurate completion of delineations. Assure complete, rapid and service-oriented initial practitioner credentialing, privileging, and provider assessment within constraints of due-diligence credentialing practices and KPNW Policies and Procedures. Audit files prior to presentation to assure completion and compliance. Issue status reports to NWP and KFH/P on progress and potential credential date. Assure complete, accurate, timely, service-oriented reappointment and reassessment within constraints of sound credentialing practices and KPNW Policies and Procedures
  • KPNW Credentials Committee and Provider Assessment Committee
  • Prepare credential, assessment, and quality paper and electronic files for chief of service, Committee peer reviewer, and Committee meeting. Identify and flag issues of concern, work with chiefs and peers to pursue information. Prepare lists, reports, documents, agendas for meetings. Prompt chairs and presenters. Track open issues, follow-up on action items. Record meetings accurately, discreetly, timely and in professional minute-style. Distribute minutes confidentially and maintain survey-ready. Assure tracking, follow-through, stamping and closure of paper and electronic files. Report to Executive Committees and Boards of Directors accurately and timely
  • Audits and Surveys
  • Maintain documentation and files survey-ready. Prepare KPNW for Internal and external audits and surveys. Meet with auditors and accreditors, respond to questions, facilitate file reviews. Know accreditation standards; achieve and maintain accreditation status. Perform/participate in KPNW audits of delegated entities and delegate’s audits of KPNW. Audit files and minutes, write reports and responses to audits. Present audit results and recommendations to Credentials Committee. Monitor and assess compliance with Credentials MOUs, identify opportunities for improvement, and ensure adequate follow-up is received as requested
  • Policies, Procedures, Forms
  • Identify need for, write, flow diagram and maintain regional Credentialing and Recredentialing Policies and Procedures, desk procedures, and credentialing/organizational assessment forms that meet the standards of state and federal legislation and accrediting body standards. At least annually review and update. Link policies, procedures, forms and practices in seamless flow. Coordinate with bylaws, Medical Directors Quality Committee standards, internal and external customers. Maintain and utilize as standard operating procedures and to direct processing of special situations. In-service other departments/practitioners affected
  • Support internal and external customers created by credentials delegation agreements. Act as NWP “office manager” facilitating document flow for KPNW practitioners. Act as “Credentials Verification Organization” and/or “Primary Admitting Facility” in relationships with delegates: provide reappointment packets to plan hospitals in accordance with MOU; pursue documents; generate and distribute rosters; provide copies of licenses, insurance, malpractice claims, CMEs. Communicate accurately, diplomatically—within procedures related to confidentiality and protection of peer reviewed material—with previous and current affiliations and medical boards across the country. Communicate with internal and external customers responsively to strengthen and maintain working relationships and delegation agreements
  • Assess potential to delegate credentialing, assessment, or any component thereof. Apply KPNW Policies and Procedures and accreditation standards to potential situation, arrive at decision, make recommendation to NWP, KFHP, Contracts Departments. Enter delegation information into paper and electronic files. Facilitate win-win relationships with delegates and potential delegates
  • Orientation
  • Orient new practitioners, staff from input and output departments, chiefs of service, Quality assurance representatives, Committee peer reviewers, plan hospital partners, service managers, and committee secretaries to the practitioner credentialing and provider assessment processes. Train, educate, elicit support, and cooperation
  • Performance Reports
  • Audit and track work ongoing. Complete accurate and timely reports to be used for reporting purposes to Northwest Permanente, the Regional Operations Group and Boards of Directors summarizing monthly activity. Participate in Healthcare Data and Information (HEDIS) data-gathering and inputting
  • Minimum one (1) year of experience in medical staff credentialing and privileging including assembly of quality files
  • Minimum two (2) years of experience credentialing
  • Previous experience preparing for and participating in JCAHO, NCQA or other external surveys
  • BA/BS degree or equivalent education and work experience
  • NAMSS CPCS or CPMSM certification maintained or willingness to pursue certification as at earliest possible time and maintain
  • Working knowledge of NCQA and JCAHO medical staff, credentialing and organizational assessment standards
  • Working knowledge and experience of office automation system, Windows, Excel, Access and credentialing software
  • Customer service oriented verbal and written communication skills
45

Credentialing Specialist Resume Examples & Samples

  • Completes all paperwork in relation to credentialing process, i.e. checklists, department approvals, approval letters, etc. and uploads forms into Cactus
  • Processes all temporary privileges in accordance with Medical Staff Bylaws
  • Enters clinical privileges into Cactus database for all privileged practitioners
  • Maintains Meditech Provider Dictionary in accordance with Corporate Policy CSG.QS.002
  • Maintains Cactus credentialing database by entering credential dates, clinical privileges, approvals, contact logs, etc
  • Enters all requests for access into eSAF program for physicians and Advanced Practice Professionals
46

Credentialing Specialist Resume Examples & Samples

  • Gathers data, reviews for completeness and accuracy, analyzes potential problems and recommends appropriate actions. Monitors timeliness and receipt of information and follow up as needed
  • Identifies questionable and highly sensitive information and refers to appropriate sources for further research
  • Enters credentialing data into system and tracks and maintains provider information
  • Performs general office duties such as filing, duplicating, sorting, mail distribution, etc
  • Works with internal department to exchange provider information and follows up on inconsistencies
  • Identifies procedural and systems problems and brings them to Supervisor's attention; makes recommendations where appropriate
  • Maintains the Professional Office Review database to track activities of office review and medical record review
  • May review reports from regulatory and controlling oversight agencies. May summarize provider files to facilitate committee review or prepare detailed documentation related to formal reviews
47

Lead Credentialing Specialist Resume Examples & Samples

  • Two years business or technical college or 2 years of experience in a hospital or health plan credentialing position; OR current CPCS or CPMSM certification and 2 years of experience in a hospital or health plan credentialing position
  • Two years experience in a hospital or health plan credentialing position
  • Excellent organizational skills, attention to detail, written and verbal communication skills
  • Must have ability to use independent judgement to perform a wide variety of tasks in a professional manner
  • Varied PC, database and work processing ability
48

Credentialing Specialist Resume Examples & Samples

  • Completing physician credential documents
  • Calling in payers to confirm physician has been added to their group
  • Update mailing address
49

Echo Credentialing Specialist Resume Examples & Samples

  • 3-5 years supporting the Echo Credentialing or a credentialing software equivalent and have successfully added new facilities from legacy systems
  • Must have an understanding of the Extract, Transform, and Load (ETL) process
  • Can manage complex SQL queries including sub-queries and joins
  • Able to analyze current business processes and standardize legacy data to comply high level of accountability and follow-through
  • Must be able to work with minimum direct supervision
  • Able to work in a deadline-driven, detailed-oriented environment
50

Credentialing Specialist Resume Examples & Samples

  • High School Diploma OR GED required
  • Two(2) years of hospital or CVO experience in credentialing preferred
  • Certified Professional Credentialing Specialist (CPCS) certification preferred
51

Credentialing Specialist Resume Examples & Samples

  • Review new applications and supporting documents in a virtual environment and apply policy and criteria required for credentialing processing
  • Perform all required primary source verifications
  • Contact hospitals, licensing agencies, malpractice carriers, and medical schools to obtain credentialing verifications
  • Maintain and update credentialing database records
  • Review malpractice history, regulatory and disciplinary action reports issued by state and federal agencies invoking appropriate processes as defined in policies and procedures
  • Review the CAQH system and download applications or supplemental documents as appropriate
  • Maintain electronic provider files
  • Demonstrate knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.)
  • Required 1+ year of experience in a hospital, provider or managed care setting
  • Required 2+ years of experience in a customer service or healthcare related position
  • Preferred Other Certified provider credentialing specialist or directly related or equivalent work experience
52

Credentialing Specialist Resume Examples & Samples

  • The Credential Specialist is responsible for communicating with and assisting facilities and staffing vendors in achieving and managing full candidate compliance per Joint Commission standards and / or client specific requirements
  • Secure full compliance for all employee starts with follow up on all compliance requirements to ensure employee credentials are up to date at all times
  • Ensures all expiring documents are communicated to our agency staff and ensure that updated documents are obtained
  • Strong trouble shooting skills and abilities
  • Possess excellent interpersonal communication skills with the ability to build successful customer relationships
53

Credentialing Specialist Resume Examples & Samples

  • Maintain electronic credentials files that meet all regulatory agency requirements
  • Serve as the person responsible for processing credentials files that contain dated, accurate approved content on time, verify professional history, communicate the status directly to providers and administrators and meet regulations
  • Monitor all aspects of the file process and evaluate for a total picture of the provider’s background
  • Process initial and re-credential files for the Medical Staff and Allied Staff within Allina
54

Credentialing Specialist Resume Examples & Samples

  • Perform verbal, written, and on-line verification of credentials for providers, medical directors, licensing agencies, accrediting bodies and other entities including, but not limited to: medical experience, state licensure, prescribing certificates, education, modality, age ranges treated, accreditation status, Medicare/Medicaid certification, programs name/ address/ intake phone number, staff roster information, and (written) validation of program no longer offered
  • Monitor work queue to ensure that acknowledgments are sent to providers within five (5) day turn-around time and email inquiries are sorted and assigned to the Reviewer on a daily basis. Record and report work volume. Maintain production levels and quality scores in accordance with set standards for a Credentialing Specialist Level III specializing in Credentialing Review and Primary Source Verification Review
  • Review and process change of address requests which consists of verifying the accuracy of the required forms and documentation i.e. license, permits, etc
  • Computer literacy and intermediate use of Microsoft office programs (Internet, Outlook, Word and Excel). Operational knowledge working with fax machines, copiers, and other office machines
  • Possess thorough knowledge and full compliance with Beacon Health Options and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations
  • Able to work in a production based environment and meet production goals
  • Demonstrate working knowledge of medical terminology; excellent oral and written communication skills; and the ability to communicate with stressful callers maintaining calmness, assertiveness and diplomacy
55

Credentialing Specialist Resume Examples & Samples

  • Obtains all applicable affiliations by utilization of verification software/databases as well as approved verification sites via the internet primary source information and references
  • Obtains all applicable education by utilization of verification software/databases as well as approved verification sites via the internet primary source information. Must remain professional throughout the call
  • Sends appropriate communication and provides follow up to practitioners
  • Ability to follow accounts through to completion
  • Record all incoming mail/supporting documentation in credentialing software system
  • Location/Facility – Baylor Corporate Office
  • Medical Staff Services Certification
  • Certified Professional Medical Services Management
  • Certified Provider Credentialing Specialist
  • Associates Degree Preferred
56

Credentialing Specialist Resume Examples & Samples

  • Credential & Re-credential behavioral health providers & facility organizations (hospitals, mental health centers, etc.) using Beacon’s Network Connects Credentialing System
  • Perform verbal, written & on-line primary source verification for individual & facility organizations including but not limited to, state licensure, prescribing certificates/registrations, education, training & certification verification, accreditation status and exclusion data-base checks
  • Monitor work queue to ensure applications are processed timely within expected turn around times while maintaining quantity & quality that meets or exceeds internal department standards
  • Computer literacy & intermediate use of Microsoft office programs (Internet, Outlook, Word & Excel) as well as Adobe PDF Creator. Optional knowledge working with fax machines, copiers and other office machines
  • Ability to work in a production based environment & meet production goals
  • Must possess a professional demeanor, strong written and oral communication skills, strong computer skills, and the ability to learn Beacon’s internal systems
57

Credentialing Specialist Resume Examples & Samples

  • Accurately enter information into Network Connect (NWC) for all potential network providers and/or existing providers being re-credentialed for the network
  • Complete provider’s TRICARE Certification for eligibility
  • Ensure provider applications are loaded into NWC and a receipt of application letter is returned within 5 business days of the receipt date of the application
  • Inventory should be reviewed daily, ensuring that applications are assigned and scrubbed for missing information within 15 days of receipt
  • Process provider applications using paper base, electronically base and through CAQH
  • Must demonstrate proof of U.S. Citizenship. The Department of Defense Contract requires U.S. citizenship for this position as well as a successful background investigation based on the completion of the Questionnaire for Public Trust
  • Excellent oral and written communication, interpersonal skills and customer orientation
58

Credentialing Specialist Resume Examples & Samples

  • Required: Excellent written and verbal communication skills
  • Required: Proficiency with basic data entry, database software, and general computer use
  • Required: Ability to type at least 35 wpm
  • Required: Ability to professionally adapt to a rapidly changing environment and rule set
  • Preferred: Knowledge of NCQA, CMS, and/or managed care credentialing criteria
  • Preferred: Software proficiency with Microsoft Word, Microsoft Outlook, Visual CACTUS, and/or Laserfiche
59

Credentialing Specialist Resume Examples & Samples

  • Possess thorough knowledge and full compliance with Beacon Health Options and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations. Maintain strict confidentiality of member and provider information
  • Possess thorough knowledge of all facility program types commercially contracted by Beacon Health Options to include full validation of compliance with clinical and credentialing criteria for such programs
  • Ability to learn quickly and a keen eye for details, analytical and problem solving skills, the ability to withstand varying job pressures and to meet deadlines and the ability to handle multiple tasks at one time with minimal supervision
  • Ability to work in a production based environment and meet production goals
  • Displays flexibility in work assignments and a positive attitude
60

Credentialing Specialist Resume Examples & Samples

  • Completes and maintains clinicians privileges and hospital appointments and reappointments
  • Maintains and updates credentialing reports
  • Research and resolves all credentialing and payer enrollment issues
  • Participates, presents and attends professional/departmental meetings
  • Works in collaboration with the Contracting Department, Revenue Operations, Clinical Operations and other areas on issues to improve processes and outcomes
  • Coordinates Peer Review activities and processes in compliance with all applicable requirements in conjunction with the Peer Review Committee
  • Ability to communicate effectively; Ability to work independently; Skilled in a variety of software applications
61

I.T Credentialing Specialist Resume Examples & Samples

  • Must have strong customer service and communication skills
  • Demonstrated ability to meet regular time and attendance requirements
  • Provides physician credentialing support utilizing the clinical application HCHB and working as part of the team that maintains the company's IS Service Desk
  • Answers first level support phone calls, email and web requests
  • Researches, resolves, and responds to end-user/problems/questions received via email, telephone calls, callbacks, web requests or escalations, and provides support on technology platforms, in accordance with current standards and service levels
  • Participates in team projects as required
62

Credentialing Specialist Senior Resume Examples & Samples

  • Requires a H.S. diploma; 4-5 years credentialing experience; or any combination of education and experience, which would provide an equivalent background
  • CPCS or CMSC preferred
  • East Coast location preferred
63

Credentialing Specialist Resume Examples & Samples

  • Proficient in Microsoft Office. Knowledge of Outlook and database systems preferred
  • Excellent communication skills both verbal and written with a willingness to provide superior customer service
  • Prior experience in a business office environment, preferably in a staffing, medical or quality assurance capacity
  • High School Diploma or equivalent, some college preferred
64

Credentialing Specialist Resume Examples & Samples

  • 1 to 3 years’ experience in Credentialing/MSO office
  • Highly motivated to achieve desired goals and objectives
  • Creative problem-solving and risk-taking skills
  • Superior leadership skills with enthusiasm, initiative and a passion for result
  • Intermediate knowledge of Microsoft Office
  • Ability to prepare and write reports, summaries of work/work projects
  • Ability to prioritize workload and meet strict deadlines
  • Ability to work in a fast-paced and fluid environment
  • Strong problem-solving skills and attention to detail
  • Ability to communicate clearly and concisely across multiple levels within the company
65

Credentialing Specialist Resume Examples & Samples

  • Ensure that appropriately completed credentialing applications are submitted to every contracted payor for each Lancaster General Health employed Physician and Practitioner (CRNA, CRNP, Physician Assistant, etc.) in a timely fashion
  • Respond timely to all written, verbal, and electronic payor requests regarding missing or additional information necessary to complete the credentialing/re-credentialing process for each Physician/Practitioner
  • Maintain the accuracy of Physician/Practitioner payor credentialing records in OneApp Pro, CAQH, PECOS, PROMISe, and other formats accepted by contracted payors
  • Provide periodic Professional Billing Services/Practice updates with regards to credentialing status of any new Physician/Practitioner
  • Research and respond to all inquiries from Professional Billing Services/Practice staff related to claims denied or underpaid for “provider not credentialed” and other related set-up issues when internal records indicate payor approval by date of service
66

Credentialing Specialist PRN Resume Examples & Samples

  • Basic computer knowledge with knowledge of word processing and database management
  • Knowledge of medical staff procedures, minute taking and medical staff office processes
  • Knowledge of MD Staff software a plus
  • Ability to learn new software programs as they are implemented to better facilitate processes
67

Credentialing Specialist Resume Examples & Samples

  • 1+ year of Medical staff Credentialing experience
  • Knowledge of Credentialing procedures, policies and terminology
  • Solid analytical and problem solving skills
68

Credentialing Specialist Resume Examples & Samples

  • Responsible for verifications for medical staff and allied health professionals initial appointments, provisional reviews, reappointments and privilege delineation
  • High School Diploma required. Associate’s Degree preferred
  • 1 year of hospital or managed care credentialing experience required
  • High level of energy to work in a fast paced environment often including time deadlines, frequent interruptions, multiple demands and multi-tasking
  • Working knowledge of State and Federal law relating to due process and provisions of the Health Insurance Portability and Accountability Act if 1996 and all applicable standards
69

Associate Credentialing Specialist Resume Examples & Samples

  • Verify all related specialty credentials, including but not limited to medicare, education, training, licenses, and malpractice/professional liability insurance as applicable
  • Enter all provider information and primary source verification data into the related database
  • Create and maintain provider files in compliance with the organization’s policies
  • Assist in preparing all required materials for FHP’s Credentialing Committee
  • Abide by all policies, procedures, and work instructions for the credentialing function of the Medicare Advantage plan
  • Assist in goals and performance standards management
  • Ensure data integrity is maintained in related credentialing database and core system records
  • Improve efficiencies and service provided while reducing costs
  • Assist with preparing files and materials for internal and external regulatory audits
  • Attend trainings and reference materials including content, work instructions, and tools
  • Obtain knowledge of credentialing regulatory and accreditation requirements (CMS, NCQA, etc.)
  • Perform monthly monitoring
  • Prepare for internal and external audits
  • Perform quality checks
70

Credentialing Specialist Resume Examples & Samples

  • Prepare and maintain reports of credentialing activities such as payer enrollment statuses, provider credentials, and client demographic data
  • Create and carry out enrollment processes in relation to physicians and other ancillary healthcare professionals as it relates to participating with insurance companies
  • Perform data entry as necessary within the designated provider enrollment software
  • Gather and maintain provider credentials and documents within a secure network location
  • Manage initial payer enrollments for new providers from start to finish
  • Monitor re-credentialing dates for all commercial and government payers to ensure timely follow up and perform re-credentialing enrollments as needed
  • Create and maintain provider CAQH (Council for Affordable Quality Healthcare) accounts
  • Establish strong relationships with insurance provider relations representatives
  • Communicate updates to key stakeholders regarding provider enrollment statuses
  • Associate’s Degree or Equivalent
  • Certification as a Credentialing Specialist such as CPCS
  • Experience working with the provider software Echo OneApp
  • Experience as a Credentialing Specialist in an ambulatory or clinical setting
71

Credentialing Specialist Resume Examples & Samples

  • Experience in managed care role, centralized credentialing office or related healthcare environment
  • Requires high proficiency with all Microsoft Office apps such as Outlook, Word and Excel
  • Knowledge of CAQH application
  • Ability to work in deadline-intense environment
  • Problem solving and customer service abilities
  • Minimum HS diploma or GED required
72

Credentialing Specialist Resume Examples & Samples

  • Performs Primary Source Verification for individual credentialing & re-credentialing
  • Maintains credentialing management documents
  • Organizes and maintains credentialing files
  • Works with Network Contracting and Provider Relations departments and other Beacon staff to ensure follow up with providers when applications are incomplete
  • Tracking of all credentialed providers for the purpose of re-credentialing
  • Ensures that all providers are re-credentialed or terminated in a timely manner
  • Accurately enter information into Beacon’s credentialing system Cactus
  • Working Knowledge of NCQA credentialing and re credentialing standards
  • Assists with the revisions and/or development of policies and procedures
  • Prepares files for CMO and Credentialing Committee
  • Effective verbal and written communications, as well as an ability to be clear and concise in all communications
  • Proven ability to work both independently and in a cross-functional team structure
  • Strong organizational skills including the ability to manage concurrent tasks and assignments with competing priorities and deadlines
73

Credentialing Specialist Resume Examples & Samples

  • Credential and re-credential behavioral health providers and facility organizations (hospitals, mental health centers, etc.) using Beacon’s NetworkConnect credentialing system
  • Perform verbal, written and on-line primary source verification for individual and facility organizations including but not limited to, state licensure, prescribing certificates/registrations, education, training and certification verification, accreditation status and exclusion data-base checks
  • Accurately and timely perform data entry of all primary source verifications and select provider demographic and practice location information into Beacon’s NetworkConnect credentialing system
  • Stay current with knowledge of NCQA credentialing standards
  • Credential and prepare credentialing and recredentialing files for weekly Medical Director submission and bi-weekly National Credentialing Committee submission
  • Monitor work queue to ensure applications are processed within expected turnaround times
  • Meet or exceed production and quality standards
  • Display a positive, constructive, and helpful demeanor
  • 2 years’ experience in insurance, medical, healthcare or related field required
  • Professional demeanor, strong written and oral communication skills, strong computer skills, and the ability to learn Beacon’s internal systems
  • Ability to learn quickly
  • Detail-oriented, analytical, highly organized and possessing problem-solving skills
  • Ability to manage varying job pressures, and meet deadlines and handle multiple tasks simultaneously with minimal supervision
  • Ability to work in a production environment and meet production and quality goals
  • Computer literacy and experience with Microsoft office programs (Outlook, Word and Excel), and internet searches. Knowledge working with fax machines, copiers and other office machines
74

Credentialing Specialist Resume Examples & Samples

  • Prior experience required in medical staff/provider services project management and administrative support
  • Must possess computer skills in database management, practice management systems, spreadsheets, graphics, and word processing (Microsoft applications preferred)
  • Strong customer service, written communications skills
  • Equivalent education or Associate’s or Bachelor’s degree in Health Business Administration
75

Credentialing Specialist Resume Examples & Samples

  • Education: High School or equivalent; Associates’ degree preferred
  • Experience: One year of healthcare or managed care related experience preferably in hospital or health plan credentialing
  • Effective analytical skills with the ability to assess compliance, record, analyze, and interpret data into meaningful formats
  • Basic computer skills: Microsoft Office, Word and Excel
  • Basic understanding of credentialing Joint Commission, NCQA, and URAC accreditation standards
  • Demonstrated ability to work both independently and collaboratively with a team and with multiple departments while being able to take full responsibility for tasks
  • Processes provider applications and re-applications including initial mailing, review and loading. Also coordinates the distribution of emails, mail outs or other documents to customers
  • Assist in the implementation of procedures and activities related to the credentialing, re-credentialing and privileging of network providers
  • Maintains provider profiling system and communicates with providers by phone and mail regarding credentialing status
  • Tracks, maintains and updates licensure: DEA and state narcotics certification or other expiring credentials. Coordinates with physician office to obtain expiring documents
  • Answers internal and external customer phone calls. Provide physicians with credentialing application status updates in a timely and professional manner. Escalate customer concerns appropriately
  • Monitors physician sanction sources and board actions. Escalates alerts appropriately
  • Performs basic data entry on credentialing applications
76

Credentialing Specialist Resume Examples & Samples

  • General clerical duties including copying, faxing, and mailing
  • Maintain electronic and hard copy filing system
  • Retrieve documents from filing system
  • Handle requests for information and data
  • Resolve administrative issues and inquiries
  • Prepare and modify documents, including correspondence, presentations, reports, drafts, memos, and emails
  • Prepare agendas for meetings and prepare schedules
  • Record, compile, transcribe and distribute minutes of meetings
  • Assures all data is entered into system and/or tracking spreadsheets in a timely and thorough manner per policy and procedures
  • Tracks and ensures that all licenses and certifications are current
  • Prepares accurate and timely reports for internal staff
  • Interfaces with Senior Management, Billing, IT, Accounting and Patient Accounts Departments
  • Demonstrates professional conduct and complies with company and departmental policies and procedures
  • Maintains systems to identify medical staff members and their clinical privileges; prepares and maintains other related records and reports
  • Monitors and suggests revisions to credentialing, onboarding, and processes as needed
  • Adheres to Adeptus Health attendance policy as outlined in the Employee Handbook
  • Proficiency with standard office equipment
  • Experience with clerical and administrative procedure such as filing and record keeping
  • Knowledge of principles and practices of basic office management
  • Must have a clear and pleasant speaking voice
  • Must be able to work independently, and prioritize workload to meet established goals and timelines
  • Must have excellent organizational skills and the ability to manage multiple projects simultaneously
  • An understanding of primary source verification of healthcare provider credentials
  • Must have exceptional verbal and written communication skills
  • Experience in provider credentialing
  • Advance Microsoft Office Suite skills
77

Credentialing Specialist Resume Examples & Samples

  • Two years of credentialing or privileging in a health care environment is required
  • One year of experience in a managed care setting
  • Must be proficient with Microsoft Office, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies
  • Must have working knowledge of NCQA standards. CPCS or CPMSM certification preferred
78

Credentialing Specialist Resume Examples & Samples

  • High school diploma or general education degree (GED) required; college certificate or degree preferred
  • 1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
  • #LI-MR1
79

Credentialing Specialist CVS Resume Examples & Samples

  • High school diploma or general education degree (GED) required; college certificate or degree preferred. 1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
  • Detailed oriented, organized with strong sense of ownership and responsibility. Must have ability to use independent judgment to manage and prioritize the multiple tasks and deadlines in a professional and positive manner. Attention to details required
  • Intermediate to advanced PC skills: Web proficiency / internet; database management; MSWord required. Experience in MD-Staff or Morrisey databases, MSExcel and MSAccess preferred
  • #LI-MR1 0
80

Credentialing Specialist Resume Examples & Samples

  • O High school diploma or general education degree (GED) required; college certificate or degree preferred. 1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
  • O Detailed oriented, organized with strong sense of ownership and responsibility. Must have ability to use independent judgment to manage and prioritize the multiple tasks and deadlines in a professional and positive manner. Attention to details required
  • O Intermediate to advanced PC skills: Web proficiency / internet; database management; MSWord required. Experience in MD-Staff or Morrisey databases, MSExcel and MSAccess preferred
81

Credentialing Specialist Resume Examples & Samples

  • Previous experience of at least three years may be substituted for education
  • Valid certification as a Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM)
  • Certification must be passed within two years of becoming eligible for exam
82

Credentialing Specialist Resume Examples & Samples

  • Continuous monitoring of licensure to ensure Clinical and Pharmacy services are in compliance with existing and/or new licensing standards
  • Maintains documents for licensing compliance including Clinical and Pharmacy Services SOPs and Work Instructions
  • Responsible for document management on indicated database
  • Provides feedback to Clinical and Pharmacy leadership on documents that need revision
  • Responsible for tracking expiration dates for all new and existing nursing and pharmacy licenses within the organization
  • Responsible for tracking new license applications to ensure timely submission per SOP
  • Responsible for utilizing all technology and resources effectively and efficiently
  • Works directly with Finance for check requests as needed per state board requirements
  • Recommends training opportunities to improve operational performance through business level data analysis
  • Guides and participates in trending activities that support the establishment of quality metrics, and continual process improvements across the organization
  • Serve as subject matter expert on state board license and Pharmacist in Charge requirements
  • The role will be dedicated to initiatives including maintenance and compliance with all licensing standards
  • Develops, writes, and communicates guides for licensees as they move towards their required licensure
  • Quality and/or process improvement experience preferred
  • Requires broad training in fields such as business administration, accountancy, sales, marketing, computer sciences, or similar vocations generally obtained through completion of a four year Bachelor's degree program or equivalent combination of experience and education
  • Proficiency in MS Outlook, Excel, Word, and PowerPoint
  • Establish and maintain relationships with business partners and other licensure stakeholders. Provide technical advice and direction to business partners related to licensure activities
  • Assess needs from State Board of Nursing and Pharmacy Boards (gathering, analyzing, documenting, and managing changes)
  • Analyze current processes to understanding their strengths and weaknesses to determine opportunities for improvements
  • Project management/process improve experience (with ability to manage competing priorities)
  • Outstanding written and oral communication, including the ability to communicate effectively to multiple levels of the organization at one time
  • Ability to work with data to present information, draw conclusions, and make recommendations to business leaders
  • Ability to balance multiple priorities at one time
83

Provider Enrollment & Credentialing Specialist Resume Examples & Samples

  • Manage and complete Provider enrollment applications
  • Extensive follow-up to ensure Provider numbers are established and linked to the appropriate group entity in a timely manner
  • Understand specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation (DEA, CV, etc.), and regulations
  • Maintain documentation and reporting regarding Provider enrollments in process
  • Retain records related to completed Provider enrollments
  • Work closely with physician recruitment and corporate resources to expedite completion of enrollment requirements including obtaining signatures
  • Maintain Provider enrollment information within the credentialing database (Vistar)
  • Establish close working relationships with credentialing coordinators, contracting department, and payer contacts
  • Consistently demonstrate competency in job required skills
  • Contribute to a pleasant and comfortable environment; demonstrate respect and maintain patient’s dignity and confidentiality
84

Credentialing Specialist Resume Examples & Samples

  • Associate's degree, or high school diploma/equivalent
  • 1+ years of data entry, customer service, medical office, provider data management, credentialing or healthcare operations i.e. claims processing, billing, provider relations or contracting experience, preferably in a managed care or insurance environment
  • Ability to thrive in a fast-paced production environment while maintaining quality
85

Credentialing Specialist Resume Examples & Samples

  • Entering provider and contract information into database
  • Scan documents into appropriate electronic storage locations
  • Performs miscellaneous job-related duties as assigned
  • Work closely with internal and external sources to expedite completion of forms and requirements and
  • A High School diploma or its equivalent is required with 3-5 years' experience that is related to the duties and responsibilities; one year of related experience in a health care setting is preferred
  • An Associate's degree in business or related field preferred
  • Professional Association; Affiliation and participation with the National Association Medical Staff
  • Familiarity with Microsoft programs, including WORD, ACCESSand EXCEL is required
  • Experience with developing reports from database applications such as ACCESS is required
  • Familiarity with use of the Internet and e-mail applications is required
  • The position involves daily contact with physicians, business executives and the public; the ability to interact in a professional and courteous manner is required
  • The ability to communicate effectively both verbally and in writing is required
  • A high level of initiative and sound judgment is required
  • Ability to manage multiple tasks in a fast paced environment is required
  • Ability to work as a member of a team is required
  • Ability to adjust to changing priorities on short notice is required
86

Credentialing Specialist Resume Examples & Samples

  • Utilizes all available resources to reach sound decisions
  • Assumes responsibility for problems and initiates actions to solve them
  • Work with others toward shared goals including participation in department problem-solving and improvement activities
  • Bring issues related to the credentialing and/or recredentialing process to the attention of management in a timely fashion
  • Foster change initiatives to ensure continuous performance improvement and service excellence
  • Participate in Joint Commission preparation and NY State DOH Survey
  • Participate in Managed Care Audits
  • Assist in preparation and mailing of correspondence required for Credentialing, when necessary
  • Provide support services and act as back up to clerical staff when necessary
  • With appropriate training, accept additional related duties, as needed
  • Participate in education programs, in-service meetings, workshops, conferences, and committees
  • Keep abreast of current literature and professional trends
  • Review and understand the Medical Staff Bylaws of each CHS Facility
  • Review and understand the Joint Commission Standards
  • Review and understand the NCQA Standards
  • 5 years of Credentialing experience in a hospital setting
  • Proficient in Microsoft Office, including Word and Excel
  • Must have the ability to prioritize and have good listening, written and oral skills
  • Excellent customer service, oral/written communication, interpersonal, and organizational skills, Well versed in the use of the Cactus Database
  • CPCS (Certified Provider Credentialing Specialist)
  • Credentialing and medical staff services experience preferably in a hospital setting
  • Proficiency in Microsoft Office is required. Advanced knowledge of Word & Excel required
  • Excellent customer service, oral/written communication, interpersonal, and organizational skills
  • Knowledge of Cactus a plus
  • Knowledge or experience with credentialing processes desirable
87

Credentialing Specialist Resume Examples & Samples

  • Basic knowledge of the health care industry including knowledge of health care acronyms, Medicare, Medicaid and Managed Care
  • Ability to organize and prioritize work with multiple and competing priorities
  • Ability to research and perform root cause analysis to issues
  • Ability to develop and maintain and effective working relationship with all customers (internally and externally)
  • Proficient use of Microsoft Office applications and internet resources
88

Credentialing Specialist Resume Examples & Samples

  • Perform provider credentialing/qualifying process to ensure all requirements are met in accordance with credentialing requirements prior to presentation to the client hospital
  • Notify and assist providers in renewing expiring credentials such as licensure, BLS, ACLS, ATLS, PALS, as required by contract while ensuring that all credentials are current at all times
  • Ensure that all credentials files are current and complete pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage, DEA and other pertinent information, per HPP and/or client facility policy and procedures
  • Assist in the credentialing process by entering/logging/scanning information into credentialing system for initial, updating, and add on applications and maintenance processes
  • Acts as point person for completing and ensuring compliance and delivery of required information to providers in a timely manner
  • At least 1 year experience in a healthcare environment (preferably in credentialing)
  • Experience providing executive support
  • Proficiency in Microsoft Office
89

Credentialing Specialist Resume Examples & Samples

  • Reviews completed files with management in accordance with established schedules
  • Maintains credential records
  • Initiates correspondence to providers, users, health plans and others as necessary to obtain requisite credentialing information
  • Certification as a Provider Credentialing Specialist (CPCS) from the National Association of Medical Staff Services, preferred
  • Excellent customer service skills and orientation
90

Credentialing Specialist Resume Examples & Samples

  • 9 months credentialing, provider services production or customer service experience
  • PC experience to include Windows, Word, Excel, and business databases
  • Organizational skills and decision-making ability
91

Credentialing Specialist Provider Enrollment Resume Examples & Samples

  • Associate Degree required, Bachelors Degree preferred
  • 3 – 5 years experience in an administrative support capacity in healthcare at the advanced level required; 5 years experience working within the insurance agency, hospital or other healthcare setting with responsibilities related to credentialing or provider enrollment preferred
  • CPCS or willing to obtain within two years
  • Understanding of the credentialing and privileging process for health plans
  • Computer Proficiency
  • Microsoft Office to include Word, Excel, Power Point
  • Ability to work with an application specific database
  • Customer service orientation
  • Ability to work well within a team structure
  • Knowledge of NCQA and delegated credentialing requirements
92

Credentialing Specialist Unc Omss Resume Examples & Samples

  • Coordinates the administration and scheduling of a variety of professional meetings, seminars, or conferences. Coordinates the planning and logistical arrangements for special events. Maintains detailed calendars and records and confirms logistics associated with events. (O)
  • Prepares a variety of office documents, records, reports, charts and graphs. Determines some format, content and presentation. Gathers, analyzes and compiles information into report format. (O)
  • Provides leadership and guidance to co-workers. (O)
  • Responds to inquiries with written explanation by interpreting established policies and procedures. Coordinates mail screening and distribution. (O)
  • Serves as primary resource with internal and external contacts on administration of office program and/or program policies and
93

Credentialing Specialist Resume Examples & Samples

  • High School diploma/GED
  • Minimum of three (3) years of experience in multi-specialty-provider credentialing encompassing government, commercial and other insurance products, with increasing responsibility during that time period, or related experience
  • Credentialing Specialist (CPCS) Certification or equivalent experience
  • Must possess strong analytical skills. Excellent communication and organizational skills required. Ability to work independently, manage multiple priorities, and meet established deadlines. Leadership, communication, customer service, multi-tasking, and computer skills are necessary for this position. Experience dealing with clinical staff as well as financial support staff required. Must be a team player
94

Credentialing Specialist Resume Examples & Samples

  • Requires High School diploma / GED
  • Provider Credentialing, enrollment, managing databases, and researching information required
  • Experience working in health care environment required
  • Microsoft Word, Excel, and Outlook experience required
  • Microsoft Access and One Note knowledge preferred
  • Experience in FACETS a plus
  • Telephone customer service experience preferred
  • Medical terminology experience preferred
  • CPCS Certification a plus
95

Temporary Credentialing Specialist Resume Examples & Samples

  • Prepares Facility/Unit and/or State requirements for each assignment according to contract guidelines
  • Build strong, trusting and professional relationships with Healthcare Administrators and Vendors nationwide
  • 2-3 years customer service experience, office setting preferred
  • Effective communication skills and professional demeanor when representing the Company to clients, candidates or other vendors
  • Well organized and detail orientated. Accuracy in assessment and documentation of credentials is crutial
  • Beginning knowledge of Human Resources issues related to confidentiality, EEOC, ADA and other related personnel issues preferred
  • Minimum of one year of successful experience in the healthcare staffing industry
96

Credentialing Specialist Resume Examples & Samples

  • Provides exceptional customer service to physicians and physician office staff members as well as internal customers, such as members of other departments. Educates physicians and physician office staff on the credentialing process and maintains ongoing contact with these individuals throughout the process
  • Obtains timely and accurate primary source verification for all credentialing functions. Completes accurate and timely data entry of all credentialing activity into physician credentialing systems. Interacts with IS Consultant to transition all manual processes to completion of processes within the physician credentialing data system. Maintains medical staff database for all physician and allied health credentialing and privileging activities
  • Identifies trends and assists in the development of action plans for purpose of performance improvement. Evaluates processes in departmental Policies andamp; Procedures and makes recommendations for changes to Medical Staff Supervisor. Develop and distribute reports as necessary utilizing physician database. Timely completion of all assigned duties
  • Interacts with and provides support to department chairmen and leadership chairmen in the preparation of meeting calendars and meeting notices. Interacts with department chairman and leadership chairmen in presentation of initial credentialing and reappointment files in preparation for the Credentials Committee. Provides clerical support as needed to the Chief of Staff and Vice Chief of Staff in scheduling ad hoc meetings. Advances department meeting minutes to the appropriate leadership committee
  • Manages various human resources functions including hiring, work assignments, coaching plans, and performance counseling
  • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.andnbsp
  • Assists the Medical Staff Supervisor in providing all credentialing, privileging and meeting support activities for the Orlando Health Medical Staff and its leadership
  • Ongoing review of processes to improve performance and meet customer needs
  • Assumes responsibility for professional growth and development
  • Skills necessary to maintain credentialing, meeting support activities, and reporting abilities relative to physician activity and statistics
  • Three (3) years experience credentialing/privileging or
  • One (1) year of credentialing/privileging experience and two (2) years of clinical experience
  • Associate degree in business, health care, accounting or related field may be substituted for two (2) years of experience
  • Bachelor degree in health, business or related field may be substituted for three (3) years of experience
  • Proficiency in Microsoft Word, Excel, Internet and significant proficiency in credentialing data system
97

Credentialing Specialist Senior Resume Examples & Samples

  • Assists with hiring of Medical Staff and Provider Services (MSPS) staff
  • Oversees staff and assists with problem-solving for difficult application or reappointment files
  • Oversees and prioritizes daily workload/projects of the Credentialing Specialists & , and oversees the timely processing of initial applications and review processes performed by Credentialing Specialists
  • Identifies necessity for staff training and directs, or participates in, that activity. Serves as mentor for the Credentialing Specialists
  • Responsible for ensuring that the credentialing of initial applicants for medical staff membership and reappointment is coordinated accurately and timely and complies with defined schedules and TJC requirements
  • Mails request for medical staff application. Assesses applications for completeness, produce verification letters, determines if further investigation is needed, work with departments and others to make sure all applications s are completed correctly and timely
  • Conduct primary source verifications
  • Manage outside requests for practitioner hospital verifications and peer references
  • Manages the collection and thorough analysis of credentialing information. Investigates issues of concern, generates reports, and presents findings and makes recommendations to the Medical Director, the OMD Director of Operations, the Department Chiefs and the Credentials Committee
  • Responsible for final review of a practitioner’s credentials file and in collaboration with the Chief Medical Officer makes determination as to whether or not the provider is a candidate for obtaining temporary privileges
  • Resolves issues regarding provider credentialing and privileging
  • Execute process for resignation/termination of medical staff
  • Suspends practice for provider non-compliance with maintaining expirables (i.e. BCLS, med license, any required certifications, DEA, malpractice, etc.). Notifies the appropriate parties of privilege suspensions/ reinstatements due to expiration
  • Manages delegated credentialing activities (processing files, conducts the preparation for and facilitates annual audits by delegating vendors)
  • Responsible for tracking and accuracy of data (re: application elements, timeframes for processing, etc.) in Provider databases, and for ensuring process deadlines are met. Communicates appropriate provider information hospital-wide
  • Lead administrative staff for the Credentials Committee,
  • Bachelor’s degree in a field related to the position
  • Direct experience in the credentialing profession
  • Minimum of three years working experience in a large multi-specialty teaching hospital or medical group practice setting
  • OR- An approved equivalent combination of education and experience
  • Experience in organizational process improvement and streamlining systems
  • CPCS (Certified Provider Credentialing Specialist) or CPMSM certification preferred, but not required
  • Knowledge of credentialing software
98

Credentialing Specialist Resume Examples & Samples

  • Reports to the Director of Clinician Services
  • Responsible for enrolling new providers with Medicare, Medicaid and other insurance plans
  • Responsible for maintaining active credentials and rosters with insurance plans
  • Responsible for managing provider enrollment and individual provider profiles
  • Responsible for monitoring plan directories to ensure accuracy
  • Works with Clinician Credentialing Specialist to ensure seamless provider onboarding
  • Minimum: 3-5 years of experience
  • Experience with Cactus credentialing software (preferred)
  • Capable of working independently as required
99

Licensing & Credentialing Specialist Licensing & Credentialing Specialist Resume Examples & Samples

  • Research and monitor changes and updates in regulations relating to licensure and general TAC compliance
  • Responsible for disseminating research to appropriate Vice Presidents of Operations and internal departments as requested
  • Responsible for preparing, processing and submitting filing packages, including enrollment applications and renewal packages, to various state departments to obtain licenses and certifications
  • Contact state regulatory agencies (including state sales, tax and business offices, Departments of Health or equivalent, Medicaid and Medicare intermediaries, and Secretary of State offices) to determine regulations required to establish licensure and compliance
  • Coordinate licensure and compliance of pre and post mergers/acquisitions and start-ups
  • Coordinate changes in ownership or address for locations and administrators
  • Communicate with internal departments regarding changes in licensure
  • Coordinate documentation changes with Reimbursement and Treasury Departments (EFT/EFC)
  • Maintain active surety bonds and coordinate with broker and state agencies for renewals
  • Resolve billing issues as it relates to Medicare and Medicaid provider numbers
  • Assist Location Director, VP Compliance and or Regulatory Affairs Director with information necessary to comply with state audits and/or survey requests
  • Assist Managed Care and Legal with information necessary for litigation and contracts
  • Update databases and maintain files for licensure
  • Track, review, and supplement licensure spreadsheet weekly to determine priorities
  • Maintain effective and constant communication with the field as well as internal departments (managed care, accounting, accounts payable, legal)
  • Maintain relationships with state and federal regulators
  • Conduct consistent follow ups with governmental agencies to facilitate/expediate licensure process and to achieve compliance goals
100

Credentialing Specialist Resume Examples & Samples

  • Responsible for ensuring providers (doctors, physician assistants, etc.) are credentialed, appointed, and privileged with health plans, hospitals and patient care facilities
  • Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications
  • Completes provider credentialing and recredentialing applications
  • Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
  • Sets up and maintains provider information in online medical credentialing databases and system
  • Tracks license and certification expirations for all providers to ensure timely renewals
  • Provides credentialing and privileging verifications
  • Position will also include some admin duties such as filing and filling in at the front desk
  • NC Tracks - NC system for billing Medicaid
  • Cardinal - Used by managed care organizations
  • CAQH
  • NPI - National Provider Identifier
  • NPPES - System for NPI registration
  • Familiarity with various insurance providers (BCBS, United Healthcare, etc.)
  • Multi-tasker
  • Computer skills - Strong Excel, Word
101

Credentialing Specialist Resume Examples & Samples

  • Credential and prepare credentialing and re-credentialing files for weekly Medical Director submission and bi-weekly National Credentialing Committee submission
  • Education: High School diploma or equivalent
  • Relevant Work Experience: 2 years’ experience in insurance, healthcare or related field required
102

Senior Credentialing Specialist Resume Examples & Samples

  • Provides technical software support for the application used for provider credentialing in coordination with Information Services
  • Remains knowledgeable of changes to software and web based credentialing applications including, but not limited to, OneApp Pro, CAQH, PECOS, PROMISe and Cactus
  • Provides training to new employees and continuing education to existing Credentialing Specialist staff
  • Serves as project lead on new Physician Practices. Coordinates and delegates assignments to Credentialing Specialist staff
  • Supports the Manager of Contracting and Credentialing with Productivity and Quality Assurance reporting
  • Assist with special projects as assigned by Manager
  • This position will have responsibility for credentialing software data, running reports, mapping application and troubleshooting
103

Credentialing Specialist Resume Examples & Samples

  • Provides exceptional customer service to physicians and physician office staff members as well as internal customers, such as members of other departments
  • Educates physicians and physician office staff on the credentialing process and maintains ongoing contact with these individuals throughout the process
  • Various human resources functions including hiring, work assignments, coaching plans, and performance counseling
104

Credentialing Specialist Resume Examples & Samples

  • High school graduate or General Equivalency Degree (GED)
  • 2 years recent experience in a hospital or credentialing setting (course work may be substituted)
  • Proficiency in computer use and database management, including Microsoft Office
  • Experience in the use of most office equipment (i.e. copier, printer, fax, scanner)
  • Associate or Bachelor’s degree in a healthcare-associated field
  • Currently certified with the National Association of Medical Staff Services (NAMSS) as CPMSM or CPSC