Credentialing Specialist

EOE Statement 

At HOPE, we are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.  Our goal is to be a diverse workforce that is representative, at all job levels, of the community we serve.  We embrace and encourage our employees’ differences in age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are proud to be an equal opportunity workplace and an affirmative action employer.  

SUMMARY  

The Credentialing Specialist is responsible for credentialing and re-credentialing HOPE client practitioners as well as ensuring enrollment with participating client health plans and payor sources. Credentialing functions include, but are not limited to, processing credentialing applications, performing primary source verifications, and updating internal database(s) in accordance with internal policies and procedures, client health plan / payor source contracts, OHCA guidelines and applicable state and federal requirements. 

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. 

Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications  

Conducts primary source verification, collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards and ODMHSAS rules and regulations. 

Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information for internal and external audits.  

Enters, updates and maintains data from provider applications into internal credentialing database and external data sets, focusing on accuracy and interpreting or adapting data to conform to defined data field uses.  

Participates in the development and implementation of process improvements for the system-wide credentialing process; prepares reports required by regulatory and accrediting agencies, policies and standards. 

Communicates clearly with providers, their liaisons, and outside agencies and community partners as needed to provide timely responses upon request on day-to-day credentialing and privileging issues as they arise. 

Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the behavioral health care industry. 

Maintain internal provider grid to ensure all information is accurate and logins are available 

Responsible for facility credentialing for all aspects of HOPE 

Update each provider’s CAQH database file timely according to the schedule published by CMS  

Apply for and renew annually all provider licenses; Professional, DEA, Controlled Substance 

Complete revalidation requests issued by government payers 

Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid  

Work closely with the Revenue Cycle Manager and billing staff to identify and resolve any denials or authorization issues related to provider credentialing  

Maintain accurate provider profiles on internal and external databases including CAQH, Echo, OHCA, NPPES, CMS and internal databases.  

Adheres to agency policy and procedures, as found in the Forms Locked drive on each computer.  Also adheres to CARF and ODMHSAS standards and criteria, federal and state confidentiality rules and regulations, and any special funding source requirements including Medicaid and HCA regulations. 

Supports and promotes a service environment for individual in need of behavioral health and/or co-occurring services that is recovery focused, welcoming, and attentive to the needs of individuals who may have experienced trauma in their lives.  Attends annual core competencies training in relationship to individuals with co-occurring disorders or who have experienced trauma in their lives. 

Establishes and maintains professional working relationships with other agencies. 

Responsible for maintaining strictest confidentiality guidelines for interactions regarding consumer and family information. 

Performs other related duties as assigned. 

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

EDUCATION and/or EXPERIENCE  

• Bachelors degree preferred but not required.  Highschool Diploma or GED + 2 years related experience will serve as equivalent 
• 2 years credentialing experience and/or behavioral health field experience preferred  

CERTIFICATES, LICENSES, REGISTRATIONS  

May be required to obtain and maintain First Aid and CPR Certifications 

May be required to complete Therapeutic Options training or approved safety training and annual updates