Provider Credentialing Specialist

Job Title:Provider Credentialing Specialist

Location: Remote (8AM-5PM EST)

Experience Required: 1+ Year of Provider Credentialing or Similar Experience

Top Skills (Must Have): Proficiency in MS Office, especially Excel; Self-starter and motivated

Summary:

As a Provider Credentialing Specialist, you will be responsible for overseeing the credentialing and primary source verification processes for practitioners and healthcare organizations. Your role will involve coordinating all aspects of the credentialing process in accordance with organizational policies and procedures.

Essential Functions:

Processing Specialist:

• Process initial and recredentialing applications from providers, ensuring compliance with departmental requirements.
• Accurately enter application data, conducting reviews for errors before submitting provider files for quality review, meeting departmental requirements.
• Process a minimum number of provider applications each month, adhering to departmental requirements.

Recredentialing/Termination Specialist:

• Prepare and distribute recredentialing groups, meeting departmental requirements.
• Complete 1st, 2nd, and 3rd requests for recredentialing packets, as per departmental requirements.
• Generate reports for various state plans/departments to identify providers who have not returned their recredentialing applications or are past due for credentialing, adhering to departmental requirements.

Ongoing Monitoring/Watch Follow-up Specialist:

• Perform follow-up for provider files on "watch" status, as required by departmental guidelines.
• Ensure timely follow-up for ongoing state license action monitoring reports.
• Ensure timely follow-up for ongoing Medicare/Medicaid sanctions monitoring reports.

Delegation Specialist:

• Maintain the minimum volume of delegated provider entries in CACTUS to meet productivity expectations, in line with departmental requirements.
• Update delegate information received from delegate groups within the required timeframes, complying with departmental requirements.

Knowledge/Skills/Abilities:

• Proficiency in multitasking and efficient time management.
• Strong written and verbal communication skills.
• Competency in computer usage and data entry.
• Familiarity with NCQA, CMS, and Molina credentialing criteria.
• Ability to adapt professionally to a dynamic and evolving environment and rule set.
• Excellent verbal and written communication skills.
• Adherence to Molina's policies.
• Punctuality and attendance to support the required quality and quantity of work.
• Maintenance of confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA).
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.

Required Education: High School Diploma or equivalent

Required Experience: 1+ year of relevant experience