Credentialing Specialist

Credentialing Specialist
"Requirements - US Citizenship / 5+ years in Credentialing

Processes credentialing and re-credentialing applications for the client. Reviews applications and prepares verification letters. Contacts various departments, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications. Provides support to the client in the collection and query of credentials of members of the client.

• Conducts Primary Source Verification (PSV) of credentials such as licenses, certifications, registrations, professional school education, postgraduate, residency, or specialty training, board certifications, work history, and current references.
• Conducts queries through the National Practitioner Data Bank (NPDB), the Defense Practitioner Data Bank (DPDB), the Department of Health and Human Services (DHHS) and TRICARE sanction data banks.
• Collects professional/peer references and completed clinical privileges, demographics, military and civilian practice history (including adverse privileging actions and malpractice history), health status, documentation of contingency and continuing education training, national provider identification number, and for non-personal services contract providers malpractice insurance information.
• Accurately loads appropriate data in the DoD Centralized Credentials Quality Assurance System (CCQAS). Keeps records and documentation of the applications and verifications maintained.
• Establishes and maintains updated CCQAS records.
• Researches and solves credentialing/re-credentialing problems; escalates more complex issues as appropriate.
• Tracks status of credentials for healthcare practitioners and provides required documents to clients to make accession, credentialing and privileging (C&P) decisions.
• Maintains relationships with Military Treatment Facilities and supported customers.
• Ensures providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities.
• Reviews records for regulatory compliance and quality assurance at a healthcare facility, insurance group, or similar organization, ensuring relevant regulations are met.

Minimum Qualifications

• US Citizen with HS diploma or GED; Bachelor's Degree in healthcare or business field preferred
• Certified Provider Credentialing Specialist (CPCS) preferred
• 2-5 years of experience performing physician credentialing at a medical group, hospital or health plan.
• Candidate must be able to pass a government background check in order to obtain a Common Access Card (CAC)

Other Job Specific Skills

• Strong customer focus, interpersonal, collaboration, written/verbal communication, prioritization and computer skills.
• Strong attention to detail and good organizational capability.
• Able to handle multiple simultaneous tasks and complete work projects in designed time frames.
• Knowledge of Department of Defense credentialing guidelines preferred.
• Experience using Centralized Credentials Quality Assurance System (CCQAS) and Defense Medical Human Resources System - internet (DMHRSi) a plus.
• Ability to handle confidential information on a daily basis in a professional manner.
• Ability to consistently maintain quality and production expectations.
• Possess proof-reading skills sufficient for auditing documents.
• Demonstrate familiarity with credentialing policies, guidelines, and regulations for the DoD credentialing process.