Credentialing Specialist

About This Role

This Credentialing Specialist position focuses on processing provider credentialing, client billing, and other operations to ensure reimbursement for behavioral health care and related services. The role primarily involves Medicaid, but may also include Medicare and private payers.

Responsibilities

• Maintain individual provider files with up-to-date information for governmental and commercial payer credentialing applications
• Maintain contracted Managed Care Organizations, commercial payers, CMS Medicare, Medicaid, PECOS, NPPES, and CAQH tracking log to ensure all necessary portals logins are active and available
• Work with individual providers to ensure each provider's CAQH database files are updated timely according to the schedule published by CMS Medicare/Medicaid and Managed Care Organizations regulations
• Complete new individual provider application for National Provider Identifier (NPI)
• Terminate enrollment with government and commercial payers upon resignation or termination of providers
• As directed, provide updated demographic information with supporting documents to outside participants, such as commercial managed care plans and contracted billing entities
• Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases
• Ensure provider-collected information is current and accurate to ensure all individual providers are credentialed and recredentialed timely
• Coordinate, monitor, and maintain the credentialing and re-credentialing process, re-credentialing, and contracting processes with insurance companies
• Contact Managed Care Organizations, Commercial plans, CMS Medicare, and Medicaid and/or other insurance agencies to follow up on several stages in credentialing
• Identify potential onboarding issues or concerns; research provides clarification, and facilitates problem resolution
• Attend internal and external trainings as needed
• Perform other tasks as needed to support the Integrated Services Billing Department

Requirements

• A high school Diploma or GED equivalent is required
• 1 year of experience in credentialing in Ohio Behavioral Health Medicaid is required
• A broad knowledge of community service systems is required
• Knowledge of electronic health record systems is required
• Excellent communication skills, both oral and written, are required
• Excellent organizational skills are required
• A valid driver's license and the ability to operate a motor vehicle is required
• An appropriate level of auto insurance coverage is required
• Ability to manage deadlines within a fast-paced, high-volume environment is required
• The ability to operate in an Internet-based, automated office environment is required