Credentialing Specialist

Job Details Conduct activities related to initial credentialing, recredentialing, delegation, facility credentialing and ongoing provider file maintenance. Conduct all processes to remain compliant with all applicable regulatory/accreditation agencies (NCQA, NYS, CMS, etc.).Accountabilities: Review applications for completeness and thereafter initiates confidential information collection, verification and documentation in accordance with established policies and procedures for continuous credentialing and recredentialing of providers. Assures data security and confidentiality by use of confidential system. This entails appropriate labeling of information and storage, and appropriately securing file cabinets and drawers. Ensures the credentialing and recredentialing of providers is coordinated in an accurate and up-to-date manner and that this information is disseminated internally and externally and in a timely manner. Collaborates with department management the streamlining and updating of credentialing processes. Closely monitors information collection and is cognizant of all information received; evaluates adequacy and quality and pursues additional information if necessary for effective and comprehensive peer review decision-making. Immediately reports to department management any providers' credentialing information identified as adverse to the provider or enrollees. Monitors system for reporting of information and quality improvement staff to ensure that a linkage of provider information is maintained in all databases (credentialing and quality assurance). Monitors system reporting for accuracy. Assists in the maintenance of system identification for staggered credential renewals. Rotate with other Credentialing Representatives throughout the various units of the Credentialing Department Assembles all verified information and prepares credentials files for presentation to the Credentialing Committee and as required for committee mailings. Ensures provider credentials have been verified within six (6) months prior to committee review for determination of privileges. Ensures that all information is accurate and compiled in a timely manner for presentation to both the Credentialing and Quality Improvement Committees. Assist managers with follow-up for all delivery system departments, facility contracting and outside vendor when necessary.Position Success Criteria:Ability to apply common sense understanding to carry out instructions furnished in oral and written form.Effective reading comprehension and attention to detailExcellent communication skills, both written and verbalStrong computer skillsFlexibility to work multiple projects/tasks simultaneously.Ability to work independently on assignmentsEducation and Experience:High School Diploma or equivalent preferred. Minimum 2 years credentialing or related experience in a health plan or provider organization required.

Created: 2024-11-02