Credentialing Specialist

1 week ago

Hillsboro, United States Willamette Dental Group Full time

Manages departmental activities to ensure quality in conducting, maintaining and communicating practitioner credentialing and provider enrollment. Serves as a resource to departments and management staff of each practice location to advance the quality of practitioners, increase patient safety of the clinic and improve quality of patient care to the practice.

Essential Position Functions

  • Compiles, evaluates and presents the practitioner specific data collected for review by credentialing committee.
  • Analyzes applications and support documents for accuracy and completeness.
  • Ensures the timeliness of verification of credentialing and recredentialing applications by preparing requests for information, notification letters, tracks responses, responds to inquiries and follows up for required information from practitioner.
  • Recognizes, investigates and validates discrepancies and adverse information obtained from the application, primary source verifications or other sources.
  • Maintains credentialing database to ensure accurate and up-to-date data is available for practitioners, management teams, departments and online directory/profiles.
  • Assists in compliance with the accrediting and regulatory agencies (i.e. Dental boards, NPDB, NCQA, CMS) in regards to credentialing while developing and maintaining a working knowledge of the statutes and laws.
  • Coordinates, compiles, and prepares reports pertaining to credentialing and payor enrollment processes.
  • Develops and updates applicable policies and procedures that support and direct organizational practices and ensure compliance.
  • Manages appropriate forms and letters for new employee orientation, credentialing and provider enrollment.
  • Identifies and reports adverse actions taken against practitioner/provider in accordance with applicable law and contractual requirements.
  • Monitors and/or reports expirables to recommend action to management teams.
  • Audits, assesses, procures and implements effectively utilizes and maintains practitioners/provider credentialing processes and information systems (efiles, reports, databases) by analyzing the needs and resources of the practice's credentialing program.
  • Notifies and reimburses for expirables for employed practitioners.
  • Participates in onboarding/orientation with education and follow up on provider enrollment process, supports practitioner through the payor enrollment process and provides back-up for training on work scope/credentialing for practice managers and practitioners.
  • Participates in audits of delegated credentialing entities.
Job Qualifications

Associates Degree in Business Administration or a related field and 3 years' experience performing similar work or an equivalent combination of education or experience which leads to the ability to perform the essential functions of the position.

Licenses, Certifications and Registrations

Certified Provider Credentialing Specialist (CPCS) preferred.

Knowledge of:
  • National credentialing standards such as NCQA and CMS.
  • Medical and dental terminology.
  • Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • Federal and state regulatory agency requirements and standards.
  • Employment law (NPDB, FCRA, Civil Rights, ADA, EEOC)
Skills:
  • Credentialing software, human resources information systems (HRIS), electronic health records (EHR) Microsoft Office, state and federal software programs and Adobe Professional.
  • Facilitates positive, professional and constructive dialogue with the goal of motivating others to accept recommendations, cooperate, change behavior or find mutually acceptable solutions.
  • Expresses thoughts clearly, concisely and effectively both verbally and in writing. Ensures a free flow of information and communication upward, downward and across the organization by actively listening and encouraging the open expression of ideas and opinions.
  • Organizes work, effectively prioritizes and sets short- or long-term goals and strategies to achieve them. Aligns communication, people, processes and resources to drive success.
  • Organizes information and data to identify/explain trends, problems and their causes. Compares, contrasts and combines information to determine underlying issues. Sees association between seemingly independent problems or events to recognize trends, problems and possible cause-effect relationships.
Ability to:
  • Communicate and analyze data and information.
  • Maintain confidentiality of information regarding credentialing matters and other sensitive personal/professional information.
  • Display a credible presence and positive image. Develops other people's confidence in self through consistent action, values and communication.
  • Transfer software skills to new software programs.
Company Overview

We provide:
  • A stable, dentist-owned private company with an eye on the future.
  • Excellent benefits including:
    • Paid time off
    • 401k $1 for $1 match up to 5% of your compensation or the IRS limit for 401(k) contributions, whichever comes first
    • Medical, dental, life and disability insurances
    • Tuition reimbursement
  • A culture of inclusivity and respect in line with our core values of health, compassion, innovation and integrity.
  • Supportive community outreach dollars and encouragement to volunteer.
  • Thorough employee orientation and onboarding.
We are:
  • A provider and employer of choice in the Northwest for 50 years.
  • Dental insurance + providers in over 50 general and specialty offices in OR, WA and ID.
  • Dedicated to proactive care to facilitate the best possible outcomes.
Willamette Dental Group is an equal opportunity employer.

We evaluate qualified candidates without regard to race, color, religion, sex, national origin, veteran status and other protected characteristics.

This job description is not meant to be an all-inclusive list of duties and responsibilities, but constitutes a general definition of the position's scope and function in the company.

This position may be exposed to PHI in the course of his/her duties, and will handle protected information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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