Credentialing Specialist

About This Role

This specialist role ensures that all affiliated physicians and independent practitioners are qualified to provide healthcare services to members. The work involves maintaining and processing credentialing information in accordance with company policies, state laws, and regulatory requirements, with recredentialing occurring at least every three years.

Responsibilities

• Appropriately handle essential functions, prioritize them, and seek assistance when necessary, performing these functions consistently and regularly using good judgment
• Learn and apply Point32Health policies consistently and seek guidance when necessary
• Maintain and process physician and provider credentialing information for new and established health plan practitioners in accordance with Point32Health’s policies and procedures, state laws, and regulatory agencies
• Assess adequate and accurate information for participation in Point32Health, including a limited knowledge of provider contract information
• Accurately and timely enter initial and existing credentialing applications into the credentialing information system (Cactus)
• Verify necessary licenses, board certification, etc., through various sources
• Review and report adverse information received through National Practitioner Data Bank (NPDB), state, and federal sanctions
• Retrieve missing and/or expired information/documentation required for credentialing
• Act as a resource for physician and provider questions relating to certification and/or credentialing process
• Identify for the Credentialing Supervisor issues of broader complexity or sensitivity that may require further action by a Medical Director or other outside source
• Daily, prepare files that meet credentialing criteria for review by the Credentialing Compliance Coordinator and/or Supervisor and presentation to daily Medical Director file review
• Prepare files that may not meet credentialing criteria for review by the Medical Directors and/or Senior Credentialing Specialist and/or Supervisor and presentation to the Quality-of-Care Committee (QOCC), including a report of adverse information
• Daily, process all practitioners under the terms and conditions of the entities’ agreement, including files credentialed through a Certified Verification Organization (CVO)
• Participate in task forces and/or other meetings as assigned
• Execute other responsibilities and projects as assigned

Requirements

• High school diploma
• 1-2 years of experience in the healthcare field
• Experience with personal computer
• Ability to appropriately identify emergency situations and follow the appropriate protocol
• Ability to maintain and manipulate a complex credentialing information system