Medical Credentialing Specialist

Description

JOB SUMMARY: Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all medical providers who provide patient care for Arlington Orthopedic Associates, P.A. (AOA). Responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities. Maintain current accurate data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications; maintain and provide reference tool(s) of current insurance network status for all AOA medical providers to all personnel involved in patient intake, scheduling, precertification, billing and collection processes.

*RESPONSIBILITIES INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:*

• Compiles and maintains current and accurate data for all AOA medical providers.
• Completes provider credentialing and re-credentialing applications; monitors applications and follows up accordingly with facility and/or insurance to ensure prompt completion.
• Keeps medical provider(s) and direct   manager aware of current state of credentialing and re-credentialing application status via e-mails, provider meetings, staff meetings.
• Maintains copies of current stat licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all AOA medical providers.
• Sets up and maintains current  accurate provider information using Council for Affordable Quality  Healthcare (CAQH) and other online credentialing databases; keeps AOA  credentialing software current at all times.
• Tracks license, DEA, professional liability, health records, and other certification expirations for AOA  medical providers to ensure timely renewals.
• Ensures practice addresses are current with health plans, agencies and other entities.
• Processes applications for appointment and reappointment of privileges at various medical facilities.
• Audits health plan online directories for current and accurate provider information.
• Keeps knowledgeable of current health plan requirements for credentialing AOA providers.
• Maintains company files with current insurance contracts/addendums, fee schedules and examples of health plan member card(s).
• Provides and maintains current reference tool(s) relative to AOA medical providers’ insurance network status for all personnel involved in patient calls, patient intake, scheduling, precertification, billing and collection processes.
• Sends company-wide announcement e-mail regarding new insurance information, updated insurance information,  provider credentialing updates, copies of new/updated member insurance card(s).
• Maintains company files with medical  provider credentialing documents in secured location.
• Maintains work area in neat and orderly manner at all times.
• Attends regular staff meetings as requested.
• Maintains strict confidentiality of provider data.
• Performs other duties as assigned by manager.

Requirements

EDUCATIONAL REQUIREMENTS:

• High School Diploma/GED or equivalent experience.
• Associate degree preferred

QUALIFICATIONS AND EXPERIENCE

• Certified Provider Credentialing  Specialist (CPCS) preferred.
• Must have 2 years of relevant credentialing experience (insurance and facility) 
• Working knowledge and understanding  of the credentialing process (insurance and facility).
• Excellent verbal and written  communication skills.
• Professional demeanor at all times with all medical and non-medical personnel.
• Detail oriented ensuring all steps in credentialing process are completed timely.
• Ability to research and analyze data.
• Ability to work independently with minimal supervision.
• Ability to work efficiently to meet  credentialing deadlines.
• Ability to establish and maintain effective working relationships with providers, management, staff, insurance contacts, and other contacts outside of organization.