Credentialing Specialist

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Job Description:

OVERVIEW OF POSITION:

The Credentialing Specialist will be responsible for all aspects of the credentialing, recredentialing and privileging processes for all medical providers who provide patient care, clinics, and facilities within the Alpine Physician Partners network. In this role, the Credentialing Specialist will be responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities and maintain up-to-date data for each provider in credentialing databases and online systems, ensuring timely renewal of licenses and certifications. Understands CMS Medicare, Medicaid, and managed care billing, credentialing and enrollment requirements and reimbursements methodologies and applies knowledge to identify, quantify, and address missing/incorrect charges. Assist in the development of resources for researching issues.

ESSENTIAL FUNCTIONS:

• Screening practitioners’ applications and supporting documentation to ascertain their eligibility.
• Identifying discrepancies in information and conducting follow-ups.
• Medicare & Medicaid enrollment and revalidation.
• Processing initial credentialing and re-credentialing applications with follow up to ensure that credentialing is completed, and providers enrolled in health plan products.
• CAQH profile creation.
• Maintenance of internal and external databases (CAQH, PECOS, NPPES).
• Initial and reappointment of hospital privileges.
• Assisting internal customers with credentialing inquiries.
• Actively participates in group leadership meetings and is accountable for presenting credentialing status for all groups.
• Coordinates and facilitates troubleshooting with payer networks to resolve any issues related to enrollments.
• Perform provider roster reconciliation with health plans and audit provider directories.
  
  

REQUIREMENTS:

• High school diploma/GED required
• Completion of two or more years of college, preferred
• 2+ years of experience working for a health maintenance organization, health plan, provider office and/or in another health insurance-related setting
• Experience with Managed Care Organizations (MCO's) and Centers for Medicare & Medicaid Services (CMS) credentialing and registration requirements
• Experience with provider and practitioner credentialing process, timeframes and appeal options; health plan design, contracting, plan policies and procedures; MCO reporting and recordkeeping requirements.
• Experience with NCQA Credentialing Standards and Guidelines, preferred
• Experience processing primary source verifications, preferred
• Experience with Credentialing Committee and case file preparation, preferred
• Ability to build professional cross functional working relationships among all levels of the organization.
• Ability to make valid judgments, formulate recommendations or action plans, and evaluate the effects of decisions and actions.
  
  

KNOWLEDGE, SKILLS, ABILITIES:

• Intermediate computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes
• Team player that develops strong collaborative working relationships with internal partners and can effectively engage and ability to build consensus among cross-functional teams
  
  

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!