Specialist, Credentialing

Responsible for the completion of the initial credentialing and re-credentialing process of providers to the network for various lines of business across the company. Maintains credentialing database and ensures provider databases are current and accurate. Provides assistance to network staff, providers, contract services, marketing, and medical affairs. Ensures compliance with external review organization standards and delegation agreements. • 35% Performs initial and re-credentialing of providers/practitioners including documenting credentialing information according to established policies/procedures. Completes primary verification of the following: state licensure, state/federal controlled substance certification, educational and/or residency background, malpractice coverage/history, hospital privileges, and previous sanctions. • 35% Maintains credentialing database and HCS data files with appropriate network indicators and effective dates. Ensures provider databases are kept current and accurate. Retrieves and interprets credentialing database information for use in various reports. • 20% Communicates (both verbally and in written form) with providers, provider relations, marketing, other credentialing departments, and various management staff relating to any urgent matters. Registers all participating providers and assists provider network personnel in maintaining and/or updating directory information. Responds to calls/correspondence from physician/provider/office staff regarding participating networks, directories, and provider credentialing. Ensures communication of provider profiling and performance information with other provider services areas. Prepares correspondence and credentialing reports as requested by management. • 10% Assembles necessary information on providers due initial credentialing or re-credentialing for presentation to credentialing committee. Attends meetings of credentialing committee as scheduled. Assists in research, redevelopment, and implementation of any new programs/projects. Performs quality control checks/reviews/oversight of delegated entities including traveling as required to perform credentialing delegation audits. Present delegated audit findings to credentialing committee.

Skills and Abilities: • Communicates with impact • Manages database files for reporting • Understands credentialing provider lifecycle

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