The Credentialing and Provider Network Specialist supports the Contracting and Credentialing Department’s needs to achieve department goals, according to the Department’s Policies and Procedures. Coordinates network provider submissions, such as, provider applications and network agreements to internal systems and departments.
Primary duties may include, but are not limited to:
- Supports all Field Representatives to obtain agreements, Credentialing and Health Plan request documentation
- Reviews and processes incoming and outgoing required paperwork, including provider credentialing applications, Welcome letters, and all other related forms, according to the Department’s Policies and Procedures.
- Receives provider applications and contacts providers for any additional supporting documentation or clarification.
- Builds file documentation and prepares file for credentialing committee review.
- Ensures credentialing information is communicated timely to all internal departments responsible for loading systems that support claims processing
- Responsible for maintaining physician credentialing database and ensuring integrity of data maintained.
- Strong organizational skills, including time management and ability to manage high-volume email correspondence
- Answers incoming telephone inquiries from providers and assists with the resolution of Contracting/Credentialing issues/needs.
- Audits credentialing packets and tracks new credentialing and re-credentialing applications
- Conduct ongoing licensure/Medicaid sanctions/Medicare Opt Out monitoring.
- Manage provider directory
- Effectively manage follow up calls and email
- Respond to provider inquiries, concerns or complaints related to the onboarding process
- Maintain both electronic and hard copies of provider agreements, registrations and or applications
- Other duties as may be assigned
Qualifications:
- High school diploma / GED required. College degree highly desirable
- 2+ years of health and/or managed care experience
- Bilingual - English/Spanish
- Ability to prioritize workload to ensure deadlines are met
- Basic to intermediate knowledge of Microsoft Applications
#J-18808-Ljbffr
