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Credentialing Specialist
3 months ago
The Credentialing Specialist supports departmental activities to ensure quality in conducting, maintaining, and communicating dentist credentialing, and enrollment. Serves as a resource to, and collaborates with, others to advance the quality of practitioners and patient safety of the facility. The Credentialing Specialist is also responsible for the quick and efficient enrollment of our providers with their approved insurance plans, per location. They ensure all provider enrollment statuses with contracted payors remain active and maintains meticulous records to set themselves up as the expert in this area. The Credentialing Specialist tracks provider enrollment by payor & location, recredentialing, and fosters healthy communication with payors, providers, and multi-departmental Elite Dental Partners teams.
ESSENTIAL JOB RESPONSIBILITIES
Conducts, participates in and maintains credentialing.
Compiles, evaluates, and presents the practitioner-specific data collected for review by one or more decision-making bodies.
Analyzes credentialing application and supporting documents for completeness and informs the practitioner of the application status, including the need for any additional information.
Performs initial or reappointment/re-credentialing for eligible practitioners.
Conducts, participates in, and maintains primary source verification.
Applies clearly defined credentialing or privileging processes to all practitioners/providers.
Operates in compliance with all local, state and Federal laws as well as Company policy and compliance standards.
Manage the providers established ADA CAQH profile and reattests every 120 days.
Stores credentialing paperwork or electronic submissions for new providers and recertification of current providers within required timeframes. Ensures provider credentialing status with all approved payors for the location in which they work.
Responds to requests regarding new providers credentialing status and recredentialing.
Maintains a provider and location roster to share with payors during the enrollment process. Modifies these records as appropriate to maintain accuracy of documents.
Submits credentialing paperwork, rosters, recredentialing information to third party payors, networks efficiently and accurately to minimize impact on patient flow.
Acts as liaison with third party payors to validate and/or correct entity and/or provider set-up in the third-party payors system.
Tracks and logs status on assigned credentialing projects and open items to completion.
Builds strong relationships and communication bridges between Credentialing team and practice teams, as well as with DSO payor contacts.
Maintains accurate detailed records of all credentialing work in addition to emails and/or conversations with third party payors, doctors, practice teams, and other Elite corporate teams.
Reviews credentialing-related issues with payors to resolution and ability to decipher if issue is related to enrollment or is claims issues. If claim issues, work with Revenue Cycle team to help them resolve.
Maintains monthly delegated credentialing spreadsheets for assigned practices.
Remains current with trends, regulatory requirements, and business strategies related to dentistry.
Supports the credentialing function through all acquisitions to ensure efficient, accurate, and timely enrollment with insurance plans at PPO locations.
Own all communication about insurance credentialing enrollment with your assigned region(s). You will be the main point-of-contact for these providers and locations and will need to work independently to run regional calls.
Other duties and responsibilities as assigned.
REQUIRED EDUCATION AND EXPERIENCE
High School Diploma required; Bachelors Degree preferred.
2-3 years of Dental or Medical Credentialing experience required (Dental preferred). This is not an entry level position.
Understanding of NCQA credentialing standards.
CPCS certification (preferred not required).
QUALIFICATIONS
Knowledge of dental insurance credentialing, ADA recommendations, CAQH Proview, and NPPES preferred.
Displays a credible presence and positive image. Uses appropriate protocol for professional and social situations.
Expertise in payor online and paper credentialing application processes.
Ability to interpret and apply third party payor credentialing requirements.
Demonstrated experience auditing and maintaining detailed complex credentialing records.
Detail oriented with a high level of organization, analytical, and problem-solving skills.
Excellent ability to remain calm in fast-paced environments.
Ability to work autonomously and efficiently within designated timeframes or deadlines.
Communicates effectively orally and in writing.
Understanding of how to deescalate a situation through careful communication choices.
Proficient with Word and Excel.
Proficient knowledge of credentialing software platforms.
PHYSICAL REQUIREMENTS
The position is remote with limited travel required to EDPs Chicago, IL. Support Center
The above statements are intended to provide a general overview and level of work being performed by most people assigned to this job. They are not intended to be a list of all responsibilities, duties and requirements. Additional duties can be assigned as determined.
Elite Dental Partners is an Equal Opportunity Employer. We support a diverse workforce
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