Medical Credentialing Specialist

Description

POSITION PURPOSE

We are seeking a detail-oriented and organized Medical Credentialing Specialist to join our team. In this role, you will ensure that all healthcare providers meet the necessary licensing, certification, and credentialing requirements for employment and participation with insurance payers. The ideal candidate will have excellent communication skills, a keen eye for detail, and the ability to manage multiple tasks in a fast-paced environment.

ESSENTIAL FUNCTIONS & BASIC DUTIES

• Credentialing and Recredentialing:
• Process initial credentialing and recredentialing applications for healthcare providers, ensuring compliance with regulatory and organizational standards.
• Verify and update provider information, including licenses, certifications, education, work history, and malpractice coverage.
• Compliance Management:
• Ensure compliance with all applicable laws, regulations, and accreditation standards.
• Monitor and track expiration dates for licenses, certifications, and insurance and notify providers of renewal requirements.
• Insurance Enrollment:
• Facilitate enrollment and participation with insurance networks and government programs (e.g., Medicare, Medicaid).
• Maintain payer contracts and assist with resolving payer-related credentialing issues.
• Database Management:
• Maintain accurate and up-to-date records in credentialing databases and systems.
• Generate and distribute reports on credentialing statuses and deadlines as needed.
• Communication and Collaboration:
• Serve as the primary point of contact for providers, payers, and other stakeholders regarding credentialing matters.
• Collaborate with internal departments to support timely provider onboarding and compliance.

COMPETENCIES

Ethics: 

• Treats people with respect. 
• Keeps commitments.
• Inspires the trust of others. 
• Works with integrity and ethically. 
• Upholds organizational values. 

Judgment: 

• Displays willingness to make decisions. 
• Exhibits sound and accurate judgment.
• Supports and explains reasoning for decisions.
• Includes appropriate people in decision-making processes. 
• Makes timely decisions.  

Planning/Organizing:

• Prioritizes and plans work activities.
• Uses time efficiently. 
• Plans for additional resources. 
• Sets goals and objectives.
• Develops realistic action plans. 

Problem Solving:

• Identifies and resolves problems in a timely manner.
• Gathers and analyzes information skillfully.
• Develops alternative solutions.
• Works well in group problem solving situations. 
• Uses reason, even when dealing with emotional topics. 

Quality:

• Demonstrates accuracy and thoroughness.
• Looks for ways to improve and promote quality. 
• Applies feedback to improve performance. 
• Monitors own work to ensure quality. 

Written Communication:

• Writes clearly and informatively.
• Edits work for spelling and grammar.
• Varies writing style to meet needs.
• Presents numerical data effectively. 
• Able to read and interpret written information. 

PHYSICAL DEMANDS

While performing the duties of this job, the employee is frequently required to talk or hear. The employee is regularly required to walk; sit; use hands to finger, handle, or feel; and reach with hands and arms. The employee is frequently required to stand and stoop, kneel, crouch, or crawl. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

The noise level in the work environment is moderate.

Requirements

QUALIFICATIONS

Education/ Certification:

• High school diploma or equivalent (bachelor’s degree preferred).

Experience/ Knowledge required:

•  Minimum of 2 years of experience in medical credentialing or a related field.
• Knowledge of credentialing processes, healthcare regulations, and insurance payer requirements.

Technical Skills:

•  Proficiency in credentialing software and Microsoft Office Suite.

Other Skills/ Abilities:

•  Strong organizational skills and attention to detail.
•  Excellent verbal and written communication skills.
• Ability t