Credentialing Audit Specialist

Salary Range: $24 - $27/ hour

Summary

Responsible for assisting with tasks to ensure that all files and processes are in accordance with NCQA (and other regulatory agency) credentialing standards and regulations. Assists Lead Credentialing Auditor prepares documents timely for onsite and virtual audits.

Duties and Responsibilities

1. Coordinates all activities related to network credentialing including, but not limited to application completeness and maintenance

2. Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up

3. Oversees preparation of credentials files for completion and presentation to MedPOINT’s Credentialing Committee.

4. Responds to inquiries from health plans and provider offices/clinics; interfaces with internal and external customers on day-to-day credentialing issues as they arise.

5. Optimizes efficiency with document generation and reporting

6. Coordinates primary source verification process with Gemini Diversified Services (CVO)

7. Enters primary source documentation in home grown credentialing database

8. Participates in credentialing committee meetings (monthly and ad hoc)

9. Assists with P & P Development in accordance with NCQA & JACHO guidelines

10. Prepares and submits all corrective action plans

11. Performs miscellaneous job-related duties as assigned and requested

Minimum Job Requirements

High school diploma or GED; at least 2 years experience with hospital medical staff or managed care credentialing. NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing the above certification highly preferred.

Skill and Abilities

· Strong written and oral communication skills.

· Excellent presentation and analytical skills.

· Knowledge of medical credentialing and privileging procedures and standards.

· Ability to analyze, interpret and prepare reports.

· Proficiency with Microsoft Office Programs; primarily Word and Excel 2013 or higher

· Knowledge of all aspects of credentialing including HDO Credentialing

· Ability to multitask and work well as a team

· Proficient in using credentialing software and databases for data entry and maintenance.

· EZ-CAP® knowledge a plus.