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Credentialing Specialist

3 months ago

Coral Gables, United States DOCTORS HEALTHCARE PLANS, INC. Full time
Job DescriptionJob Description

Scope of Position:

Maintain an efficient provider credentials system by ensuring completed credentials CAQH profiles and/or applications are received and processed, correct data entry, and updated regulatory and credentialing documents are entered and/or scanned into the Doctors HealthCare Plans, Inc, (“DHCP”) credentialing CACTUS database, provide data entry and clerical support to the Credentialing Department.  This position will assist the Credentialing Department in the timely processing of Initial Credentialing / Recredentialing of application, processing incoming and outgoing documents, and requesting required credentials documents.

Essential Job Functions:

  • Processing practitioner credentialing and recredentialing application packets which includes:
  • Reviewing each credentials application packet for completeness and requesting missing data from the practitioner offices and/or Contracting Department staff;
  • Creating a new electronic record in the credentialing database and perform data entry of all Initial (new) and Reappointment (recredential) Practitioners (MD, DO, DPM, OD, CH, PA, NP, MW, MSW, CSW, LCSW, MFT, RD, LN, and Ancillaries) credentials applications;
  • Requesting by telephone, electronically, fax or mailings State licenses, Drug Enforcement Agency (DEA) certificates, Liability insurance, National Practitioner Database (NPDB) Report, Office of Inspector General (OIG) reports, Board certification, School/Residency/Fellowship  completion, Hospital privileges verification, System Award Management (SAM), Claims history, Accreditation (ancillary facilities), Site Visits and obtaining additional information or clarification from practitioner offices as needed;
  • Creating file folders for each new practitioner (e.g. Physician, Ancillary, and or Allied Health Practitioners).
  • Processing practitioner recredentialing application within 3 years of initial credentialing date.
  • Processing and maintaining delegated entities’ files, submitted documents and perform data changes which includes:
  • State licenses, DEA certificates, Liability insurance, NPDB report, OIG reports, SAM report, Board certification, Hospital privileges verification, claims history, Accreditation (ancillary facilities), and obtaining additional information or clarification from practitioner offices as needed;
  • Creating and/or updating electronic records in the credentialing database by entering data, faxing, and/or scanning;
  • Filing or scanning documents received.
  • Assisting Credentialing Director or designee with various tasks, as needed.
  • Receiving, sorting, and distributing incoming mail and faxes as needed.
  • Maintaining thorough operational knowledge of the DHCP Credentialing CACTUS Database.
  • Maintaining thorough operational knowledge of the appropriate Credentialing Policies & Procedures.
  • Annually providing input into updating Credentialing Procedures.
  • Performing other related duties as required.
Qualifications:
  • Minimum of two (2) years previous experience in a managed care organization’s Credentialing department.
  • NAMSS CPCS certification is preferred, or a commitment to pursue certification within two years.
  • Knowledge of basic medical terminology.
  • Ability to analyze data and make appropriate decisions.
  • Ability to work as a team under stressful conditions.
  • Good verbal communication skills
  • Bilingual English and Spanish - (preferred but not required)
  • Excellent organizational skills.
  • Extremely detail-oriented.
  • Ability to maintain confidentiality.
  • Minimum typing skills of 45 WPM.
  • PC proficiency and Windows-based software knowledge (Microsoft Word, Excel, Outlook) required.

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   
 

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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