Job Description

Essential Duties and Responsibilities:

 The HP Credentialing Specialist, under general supervision, work with physicians and allied health providers to facilitate the health plan credentialing / enrollment process to ensure that complete and accurate information is forwarded to health plans in a timely manner.  As required by Credentialing Department policy, initiate follow-up with providers and health plans to ensure the process is continuing without unnecessary delays.  Follow process to completion resulting in provider becoming contracted and receiving a specific provider identification number from each health plan in order for the billing process to commence.

  • Process health plan enrollment / credentialing applications for physicians and allied health providers.
  • Review and analyze provider’s returned paperwork to ensure completeness of information.
  • Identify and flag adverse information received from materials completed by the provider for the purpose of conducting special investigation; reporting this information to the Credentialing Specialist for follow-up.
  • Maintain tickler system outside of the credentialing database for follow-up of outstanding paperwork and unanswered correspondence according to schedules designed to maintain department standards for application processing time.
  • Run weekly reports from the credentialing database to determine required follow-up with providers and health plans.
  • Enter contact and action notes into credentialing database to maintain accurate record of progress with health plans.
  • Maintain credentialing database and billing database updating provider health plan identification numbers and other required database fields.
  • Organize and maintain provider health plan files and information following confidentiality guidelines.
  • Share updated information (i.e., address changes, updated licensing or certification documentation) received from the provider during the enrollment / credentialing process with the Credentialing Specialist for input into the credentialing database.
  • Employ public relations skills in a wide variety of contacts with internal and external sources for purposes of soliciting information essential to health plan enrollment / credentialing.
  • Establish and maintain a professional working relationship with providers, their outside office staff, internal staff, and health plan staff.
  • Proficient in the use of Visual Cactus (credentialing database) to enhance the health plan credentialing process and become proficient with its reporting functions.
  • Proficient in the use of Microsoft Word and Excel for Visual Cactus; NPI (National Practitioner Identification on-line access); Certifacts (American Board of Medical Specialties on-line access); State licensing agencies on-line access and Internet Explorer for other internet access.
  • Perform varied clerical / secretarial support functions
  • Perform related duties as assigned by supervisor.
  • Maintain compliance with all company policies and procedures. 

Requirements:
Experience:

  • One year of credentialing or medical administrative experience in a hospital, managed care, or physician office practice setting is preferred.

Education:

  • High school diploma or equivalent
  • Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.

Knowledge/Skills/Abilities:

  • Understanding of the basic process for enrolling / credentialing providers with health plans.
  • Understanding of each health plan’s requirements for completion of all necessary paperwork needed for credentialing / enrollment process.
  • Understanding of the need of the credentialing process in the health care environment and the impact on quality patient care.
  • Basic knowledge of claims billing and/or contracting
  • Familiarity with the National Association for Quality Assurance Standards and Guidelines for MCO accreditation.
  • Problem solving and decision making
  • Understanding/compliance of HIPAA laws and regulations
  • Computer proficiency (MS Office – Word, Excel and Outlook)
  • Highly organized with excellent attention to detail and a demonstrated high regard for clerical accuracy
  • Excellent verbal and handwriting skills
  • Ability to read, extract and interpret information comparing such to established departmental policies
  • Excellent customer services and public relations skills required
  • Must be flexible and willing to work extra hours during peak workloads and deadlines
  • Ability to work as a team player with willingness to assist other team members as needed.
  • Must be able to work under pressure and meet deadlines
  • Self-motivated with the ability to work independently and to carry out assignments to completion within parameters of instructions given, established timeframes, prescribed routines, and standard accepted practices.
  • Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners and shredders.
  • Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.
  • Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards
  • Ability to type __35__wpm

Physical Requirements:

  • Must be able to lift and carry up to 20 lbs
  • Must be able to talk, listen and speak clearly on telephone
  • Requires sitting and standing associated with a normal office environment.
  • Manual dexterity needed for using a computer keyboard.
  • Specific vision abilities include close vision, distance vision, depth perception and the ability to adjust focus.

 

Environmental Working Conditions:

  • Normal office environment.
  • The noise level of the work environment is usually low to moderate.
  • Occasional overtime maybe required and/or hours may be shortened as business needs dictate.

*The job holder must demonstrate current competencies applicable to the position.