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:
- 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.
- Works closely with HR to ensure candidates have completed and submitted all required documents prior to On-Boarding.
- Reviews all applications for completeness and accuracy ensuring that all information meets federal, state, or commercial insurance guidelines when processing applications.
- Ensures that provider medical licenses, board certifications, DEA and other pertinent information is renewed prior to expiration.
- Assists with provider CAQH enrollment.
- Assists with federal and commercial insurance program enrollment and maintenance.
- Performs all other contracting and maintenance needs required by payors.
- Utilizes software to help maintain, track, and update all insurance payor contracts for multiple practices in multiple states.
- Maintains and updates credentialing insurance matrix and rosters.
- Manages and maintains relationships with all payors to improve revenue.
- Follows written and verbal instructions from the Director of Revenue Cycle Management.
- Exhibits professionalism in communication with payers and co-workers.
- Participates in special projects.
- 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.
- 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.
- Performs other duties as assigned.
Essential Functions:
- Must be able to lift and/or move up to 25 pounds.
- While performing the duties of this job, the employee is frequently required to sit, stand, walk and talk.
- Frequently required to bend and reach to fulfill job duties.
Requirements, Special Skills or Knowledge:
- High School diploma or GED.
- 5 years of administrative experience.
- Experience working in a fast-paced, highly accountable environment.
- Experience prioritizing and engaging in constructive feedback and quality improvement.
- Expert critical thinking, analytics, problem-solving and sound decision-making skills
- Experience interacting and communicating effectively with individuals at various levels both inside and outside the organization, often in sensitive situations.
- Proficient skills with Microsoft Office and Adobe software.
Preferred Requirements, Special Skills or Knowledge:
- Associates degree or equivalent combination of experience and education.
- Medical credentialing experience.