Credentialing Specialist - Remote

Job Summary
Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria in order to minimize liability to the company and to maximize safety for members.
Knowledge/Skills/Abilities
Responsible for coordinating assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations according to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability. Maintains a high level of confidentiality for provider information. Typically assigned the more complex work; works on special projects as assigned; and serves as a 'mentor' to newly hired Associate Specialists.
Duties to include any combination of the following:
Processing Credentialing Applications

• Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.
• Communicates with health care providers to clarify questions and request any missing information.
• Updates credentialing software systems with required information.

Recredentialing/Termination

• Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.
• Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
• Completes data corrections in the credentialing database necessary for processing of recredentialing applications.
• Reviews claims payment systems to determine provider status, as necessary.

Ongoing Monitoring/Watch Follow-up

• Completes follow-up for provider files on ‘watch' status, as necessary, following department guidelines and production goals.
• Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
• Reviews and processes monthly Medicare Opt-Out reports to determine if any provider has opted out of Medicare.
• Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found..

Job Qualifications
Required Education
High School Diploma or GED
Required Experience

• Minimum of 3 years experience in credentialing.
• Experience in a production or administrative role requiring self-direction and critical thinking.
• Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.
• Experience with advanced written and verbal communication.
• Required knowledge of CMS, NCQA and other credentialing regulations.

Preferred Education
Associate's or Bachelor's Degree
Preferred License, Certification, Association
N/A
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $14.76 - $31.97 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Health insurance