Credentialing Specialist

Credentialing Specialist - Medicare

Spring Hill, Florida - In office or remote

Position Summary: Responsible for ensuring providers and facilities have the appropriate credentials to participate and become part of the network a Medicare Advantage program setting. In addition, this position ensures providers standards set by CMS and NCQA. The Credentialing Specialist will review applications, verify both individual and facility accreditation, maintain records of verification as outlined by Ultimate Health Plans (UHP) policies and procedures.

Essential Duties and Responsibilities include the following:

• Reviews practitioner applications for completeness and collects data within defined timeframes.
• Reviews and documents findings of practitioner credentials to include the following credentialing processes; licensure, OIG, SAM, CMS/MED, AHCA, Terrorism Sanctions, Medicare Opt-Out, preclusion list, NPDB, AMA or other board certs, and hospital Privileges.
• Responsible entering completed application data into the credentialing system including demographics, personal information and identifiers, practices and work history, specialties, education, hospital privileges, insurance, and IPA association.
• Verifies provider affiliation with group (i.e., IPA, Specialist and/or Facility groups) contract.
• Adheres to strict confidentiality guidelines and Code of Conduct standards; conforms to defined processes in compliance with quality standards and regulatory requirement.
• Oversees the re-credentialing application process for mailing, monitoring, and processing of applications sent and received.
• Ensures internal monitoring form for all re-credentialed providers is routed for signature to appropriate management personnel and filed with the re-credentialed application.
• Monitors expiration reports and document results in Credentialing System by running and printing the expiration reports for providers and facilities to determine the expiration date and gather appropriate documentation to satisfy CMS and NCQA credentialing requirements.
• Ensures electronic and hard copy filing of all credentialing and re-credentialing files to the appropriate folder.
• Prints and files provider changes requests in the credentialing folder for each provider and facility.
• Works collaboratively to assure the credentialing department meets monthly performance goals, including timeliness and productivity requirements.
• Supports departmental special projects and consistently promotes process improvement.

Education and/or Experience

Associate's degree (A. A.) or equivalent from two-year college or technical school; 3 plus years related experience and/or training; or equivalent combination of education and experience.

Job Type: Full-time

Pay: $20.00 - $22.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Experience:

• Microsoft Office: 1 year (Preferred)
• Microsoft Word: 1 year (Preferred)

Ability to Relocate:

• Spring Hill, FL 34609: Relocate before starting work (Required)

Work Location: Hybrid remote in Spring Hill, FL 34609