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Form of workJob description
Credentialing Specialist
$60,000 - $70,000
OVERVIEW:A Credentialing Specialist will operate all aspects of the health plan and governmental credentialing processes. They will be responsible for Credentialing Applications, renewals, private and governmental plans including Medicaid, TriCare, Tribal, and the Veteran's Administration systems.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Must have in-depth and proven knowledge of managed care concepts, industry terms, (re)credentialing lifecycle.
- Develop strong relationships with internal stakeholders, including Facility and Corporate, as well as Payor representatives.
- Confidence and experience handling escalation processes to achieve desired outcomes.
- Proactive nature, intellectual curiosity and proven ability to research unknowns (Payors, Markets; Agencies)
- In-depth knowledge of national and local payors and markets throughout the country.
- Possess strong critical and strategic thinking, ability to follow instructions, with big picture in mind.
- Ensure the appropriate processes are in place to monitor and maintain systematic and timely (re)credentialing efforts with various health plans and facilities throughout the United States.
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to working within changing priorities, processes, and requirements.
- Knowledge and understanding of provider relations as it relates to all aspects of (re)credentialing.
- Strive to limit the usage of non-participating agreements, by evaluating the utilization of non-pars and the financial ability to ensure revenue is obtained.
- Support other functional areas, including business development, RCM, and UR with reports and data relating to all contracts and credentialing.
EDUCATION, EXPERIENCE, and TRAINING:
- Experience and success(es) in provider (re)credentialing.
- Experience in managing/maintaining current CAQH profiles.
- Strong knowledge of managed care and Medicaid, preferred.
COMPUTER SKILLS:
- Proficiency in MS Office, document tracking or similar software in addition to more general office computer systems.
