Credentialing Specialist

About This Role

Ensuring the thorough and accurate investigation of backgrounds and credentials for all practitioners and facilities contracted to provide care to Health Plan members is the core of this role. This position evaluates the adequacy of information from applicants for initial and re-credentialing, oversees primary source verification, and clarifies any discrepancies. It also summarizes and reports investigation results to the Medical Director and Plan Credentialing Committee, ensuring compliance with regulatory requirements and accreditation standards.

Responsibilities

• Ensure thorough and accurate investigation of background and credentials for all practitioners and facilities contracted to provide care to Health Plan members
• Evaluate adequacy of information presented by all applicants for initial and re-credentialing
• Direct and oversee primary source verification of all credentialing elements
• Ensure clarification of any discrepancies discovered in the verification process
• Accurately summarize and report the results of each investigation to the Medical Director and Plan Credentialing Committee
• Provide written follow-up regarding credentialing determinations, as required
• Ensure processes demonstrate compliance with State, Federal, and National regulatory requirements and the accreditation standards of the National Committee for Quality Assurance (NCQA) and Medicare (CMS)

Requirements

• High school diploma or equivalent
• 1 – 3 years related experience
• Strong communication skills in English, both verbally and in writing with provider applicants, applicants’ staff, the Medical Director, the Credentialing Committee, and other departments within the organization
• Highly detail-oriented with strong organizational and prioritization skills
• Ability to complete job responsibilities of a confidential nature, with significant accountability and accuracy to meet established timelines
• One year physician office or related medical care experience required
• Excellent computer skills including word-processing, databases, spreadsheets, and graphics
• Well-developed professional interpersonal written and oral communication skills
• Strong organizational skills with the ability to prioritize multiple tasks/projects using established protocols and guidelines to determine the appropriate course of action and meet established timelines
• Strong customer service skills that contribute to a customer-oriented team and department
• Motivated, flexible, and a self-starter
• Assertiveness, creativity, and good problem-solving skills

Nice to have:

• Medical staff office experience preferred
• Credentialing experience strongly preferred