Job Description

Department : Billing

Position : Credentialing Specialist

Employee Category : Non-Exempt

Reporting Relationship : Credentialing Supervisor

Character First qualities:

• Decisiveness- The ability to recognize key factors and finalize difficult decisions.
• Dependability- Fulfilling what I consented to do, even if it means unexpected sacrifice

• Initiative - Recognizing and doing what needs to be done before I am asked to do it.
• Thoroughness - Knowing what factors will diminish the effectiveness of my work or words, if neglected.
• Flexibility - Willingness to change plans or ideas without getting upset.

Summary of Duties and Responsibilities:

The Credentialing Specialist is responsible for collecting and confirming provider information in order to process and file reports with accrediting and licensing agencies as well as maintaining a database of provider information. They work closely with insurance companies and government payers to supply provider and client information.

Primary Duties and Responsibilities :

1. Manages the initial and re-appointment application process by working with providers to complete paperwork timely and assisting with obtaining outstanding documents and verifications to meet established deadlines.
2. Works closely with HR to ensure candidates have completed and submitted all required documents prior to On-Boarding.
3. Reviews all applications for completeness and accuracy ensuring that all information meets federal, state, or commercial insurance guidelines when processing applications.
4. Ensures that provider medical licenses, board certifications, DEA and other pertinent information is renewed prior to expiration.
5. Assists with provider CAQH enrollment.
6. Assists with federal and commercial insurance program enrollment and maintenance.
7. Performs all other contracting and maintenance needs required by payors.
8. Utilizes software to help maintain, track, and update all insurance payor contracts for multiple practices in multiple states.
9. Maintains and updates credentialing insurance matrix and rosters.
10. Manages and maintains relationships with all payors to improve revenue.
11. Follows written and verbal instructions from the Director of Revenue Cycle Management.
12. Exhibits professionalism in communication with payers and co-workers.
13. Participates in special projects.
14. Supports Variety Care's accreditation as a Patient-Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable. Provide leadership and work with all staff to achieve the goals of the "Triple Aim" of healthcare reform-to improve the experience of care, improve health outcomes, and decrease healthcare costs.
15. Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment. Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.
16. Performs other duties as assigned.

Essential Functions :

1. Must be able to lift and/or move up to 25 pounds.
2. While performing the duties of this job, the employee is frequently required to sit, stand, walk and talk.
3. Frequently required to bend and reach to fulfill job duties.

Requirements, Special Skills or Knowledge:

1. High School diploma or GED.
2. Five years of administrative experience.
3. Experience working in a fast-paced, highly accountable environment.
4. Experience prioritizing and engaging in constructive feedback and quality improvement.
5. Expert critical thinking, analytics, problem-solving and sound decision-making skills
6. Experience interacting and communicating effectively with individuals at various levels both inside and outside the organization, often in sensitive situations.
7. Proficient skills with Microsoft Office and Adobe software.

Preferred Requirements, Special Skills or Knowledge:

1. Associates degree or equivalent combination of experience and education.
2. Medical credentialing experience.

Job Tags

Work at office

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