Credentialing Specialist

JOB SUMMARY

The Insurance Credentialing Specialist is responsible for the quick and efficient enrollment of our providers with their approved insurance plans, per location. They ensure all provider enrollment status with contracted payors remains active and maintain meticulous records to set themselves up as the expert in this area. The Insurance Credentialing Specialist tracks provider enrollment by payor & location, recredentialing, and fosters develops healthy communication with payors, providers, and multi-departmental Elite Dental Partners teams

ESSENTIAL JOB RESPONSIBILITIES

• Obtains all provider credentials and documentation from the Compliance team.
• We will manage the provider's established ADA CAQH profile and retest every 120 days. The doctor can opt in or out of this (if they choose to manage it themselves).
• Stores credentialing paperwork or electronic submissions for new providers and recertification of current providers within required timeframes. Ensures provider credentialing status with all approved payors for the location in which they work.
• Responds to requests regarding new providers credentialing status and recredentialing.
• Maintains a provider and location roster to share with payors during the enrollment process. Modifies these records as appropriate to maintain accuracy of documents.
• Submits credentialing paperwork, rosters, recredentialing information to third party payors, networks efficiently and accurately to minimize impact on patient flow.
• Acts as liaison with third party payors to validate and/or correct entity and/or provider set-up in the third-party payors' system.
• Tracks and logs status on assigned credentialing projects and open items to completion.
• Builds strong relationships and communication bridges between Credentialing team and practice teams, as well as with DSO payor contacts.
• Maintains accurate detailed records of all credentialing work in addition to emails and/or conversations with third party payors, doctors, practice teams, and other Elite corporate teams.
• Reviews credentialing-related issues with payors to resolution and ability to decipher if issue is related to enrollment or is claims issues. If claim issues, work with Revenue Cycle team to help them resolve.
• Maintains monthly delegated credentialing spreadsheets for assigned practices.
• Remains current with trends, regulatory requirements, and business strategies related to dentistry.
• Supports the credentialing function through all acquisitions to ensure efficient, accurate, and timely enrollment with insurance plans at PPO locations.
• Own all communication about insurance credentialing enrollment with your assigned region(s). You will be the main point-of-contact for these providers and locations and will need to work independently to run regional calls.
• Operates in compliance with all local, state and Federal laws as well as Company policy and compliance standards.
• Other duties and responsibilities as assigned.

REQUIRED EDUCATION AND EXPERIENCE

• High School Diploma required; Bachelor's Degree preferred.
• 2-3 years of Dental or Medical Credentialing experience required (Dental preferred). This is not an entry level position.

QUALIFICATIONS

• Knowledge of dental insurance credentialing, ADA recommendations, CAQH Proview, and NPPES preferred.
• Expertise in payor online and paper credentialing application processes.
• Ability to interpret and apply third party payor credentialing requirements.
• Demonstrated experience auditing and maintaining detailed complex credentialing records.
• Detail oriented with a high level of organization, analytical, and problem-solving skills.
• Excellent multi-tasker with ability to remain calm in fast-paced environments.
• Ability to work autonomously and efficiently within designated timeframes or deadlines.
• Communicates effectively orally and in writing.
• Understanding of how to deescalate a situation through careful communication choices.
• Proficient with Word and Excel.

PHYSICAL REQUIREMENTS

• The position is remote with limited travel required to EDP's Chicago, IL. Support Center

The above statements are intended to provide a general overview and level of work being performed by most people assigned to this job. They are not intended to be a list of all responsibilities, duties and requirements. Additional duties can be assigned as determined.

Elite Dental Partners is an Equal Opportunity Employer. We support a diverse workforce.