Job Description

Function:

The Credentialing Specialist ensures active status for all providers with all applicable payers by completing initial and subsequent credentialing packages as each payer requires.  This position also assists unlicensed clinicians with the licensure process and ensures that all currently licensed clinicians maintain active licensure. 

Organizational duties & responsibilities:

1. The primary responsibility of all staff is to ensure the safety and well-being of all RE clients.
2. Supports the mission, vision, and values of RE.  Facilitates and adheres to the agency’s code of ethics, policies, and procedures.
3. Supports all functions that attain and maintain accreditation and compliance with regulatory agencies.
4. Supports and facilitates positive interaction with clients and staff by exhibiting both on campus and in public when carrying out job duties:  individual maturity, respect for others, a team-centered approach, maintenance of confidential information, and an awareness and sensitivity to cultural and other differences in clients and staff.
5. Exhibits effective communication skills, including proper use of agency communication systems.
6. Participates in appropriate professional development programs to attain and maintain competency.
7. Effectively manages financial and physical resources to achieve the mission of RE.
8. Reports incidents of abuse or potential abuse involving clients to the appropriate authorities and RE.

Essential Duties and Responsibilities:

1. Responsible for compiling and maintaining current and accurate data for all providers.
2. Responsible for Data entry and maintaining provider information in online credentialing databases and systems (CredentialStream, CAQH, PECOS, and NPPES).
3. Responsible for PrimeSource Verification of State license, DEA, and Board certification.
4. Responsible for completing provider initial and re-credentialing applications.
5. Audits applications for accuracy and completeness.
6. Responsible for revalidation requests issued by government payers.
7. Responsible for submitting completed credentialing application and supporting documentation to all requested payers.
8. Responsible for monitoring application progress and following up with payers as needed until confirmation of “in network” status has been received.
9. Responsible for maintaining copies of current state licenses, DEA certificates, malpractice coverage, and any other required credentialing documents for all providers. In addition to tracking all state licenses, DEA, and board certification expirations for all providers to ensure timely renewals.
10. Responsible for tracking CME and sending quarterly updates to providers.
11. Utilizes strong research skills to gather pertinent information regarding providers.
12. Performs all other duties as assigned.

Working conditions/environment:

1. Shift is generally dayshift, Monday - Friday.
2. Holidays, weekends, and extra hours may occasionally be required.
3. Office setting with extensive computer usage.
4. Fast-paced environment with the need for quick decisions to deal with any crisis that may arise.

minimum job requirements:

High School Diploma or GED required

A minimum of two years of credentialing experience in a managed care setting, or at least four years of related experience and training, is required.
A minimum of one year of payer provider enrollment is required.
Working knowledge of credentialing accreditation regulations, policies, and procedures.
Certified Provider Credentialing Specialist (CPCS) designation is preferred.

Must be at least 21 years of age.
Technical requirements include proficiency with Microsoft Word, Excel, PowerPoint, and any other applications used by the organization or regulatory agencies.
Familiar with provider credentialing and recredentialing requirements.
Strong analytical, computer, and software skills.
Excellent interpersonal skills, including excellent verbal and written communication skills.
Ability to demonstrate a high degree of trust and confidentiality.
Ability to work independently and assume assigned responsibilities.
Skilled in efficiency, organization, time management, and prioritization.
Ability to be flexible and function well in a fast-paced environment.
Ability to deal with problems involving several concrete variables in standardized situations.
Ability to communicate effectively and relate to people of different cultures.
Ability to handle confidential information.
Ability to understand and relate to the needs of clients from diverse backgrounds.
Ability to read, write, and converse in English.
Successful completion of a pre-employment drug screen.
Successful completion of a background screening.
Successful completion of a TB skin test or proof of a negative chest x-ray or other documentation.

Successful completion of Excellent Foundations
Maintain 20 hours of annual training

Physical Requirements:

The physical requirements described here must be met by an employee to perform the essential functions of this job successfully.  Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee is regularly required to stand, sit, walk, talk, hear, reach with hands and arms, and use hands to finger, handle, and feel.  This employee is also regularly required to use a computer keyboard and mouse.  The employee is occasionally required to stoop, kneel, crouch, and climb stairs.  The employee must occasionally lift and/or move up to 10 pounds or more.  Specific vision abilities required by this job include close vision, distance vision, and peripheral vision.

Supervisory Requirements:

N/A

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