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Credentialing Specialist

2 months ago

Leesburg, Florida, United States CAN Community Health Full time


Position Overview:

The Credentialing Specialist plays a vital role in the Credentialing Department by managing administrative responsibilities associated with the onboarding and offboarding of healthcare practitioners, credentialing processes, and health plan enrollment.

This role also involves supporting demographic updates for physicians and ancillary providers within the clinical practice.

The Credentialing Specialist is responsible for monitoring provider certifications and licensure expiration dates, ensuring that all healthcare providers uphold current credentials and comply with regulatory standards.

This position frequently interacts with healthcare providers, practice administrators, billing vendors, and both commercial and governmental health plans, as well as credentialing vendors.

Core Values:
Recognize and affirm the unique and intrinsic worth of every individual.
Treat all stakeholders with compassion and kindness.

Conduct business and personal affairs with absolute honesty, integrity, and fairness.

Trust colleagues as essential members of our healthcare team, pledging to treat one another with loyalty, respect, and dignity.


Key Responsibilities:
Uphold and promote the mission and values of CAN Community Health Inc while adhering to its policies and procedures.
Ensure confidentiality is maintained by the entire team regarding patient/client information in compliance with HIPAA and professional standards.

Main Duties:


Collaborate with the Credentialing & Health Plan Enrollment Team Lead and Credentialing Specialists to guarantee that physicians and ancillary providers are appropriately licensed and credentialed.

Provide consistent and timely follow-up throughout the credentialing process for healthcare providers, including initial credentialing, re-credentialing, and health plan enrollment.

Assist in maintaining an up-to-date provider database to confirm that all healthcare providers are licensed, insured, and credentialed according to regulatory guidelines.

Ensure all credentialing documentation is accurate, complete, and compliant with regulatory standards and health plan requirements.
Support the review process of health plan provider rosters and directory reviews/attestations.
Participate in provider profile audits across multiple systems.
Communicate with healthcare providers, health plans, and regulatory agencies to resolve credentialing issues and ensure timely processing.
Coordinate with internal departments to gather necessary information and documentation for credentialing purposes.
Compile and maintain accurate records of credentialing and enrollment activities, including tracking deadlines and expiration dates.
Engage in quality improvement initiatives to enhance the efficiency and effectiveness of credentialing and enrollment processes.
Assist clinical providers with CAQH applications on behalf of CAN employed providers.
Maintain copies of current state licenses, DEA certificates, malpractice coverage, and any other required credentialing documents for all providers.
Ensure adherence to healthcare regulations, standards, and payer requirements during the credentialing and enrollment process.
Stay informed about healthcare regulations, accreditation standards, and health plan policies related to credentialing.
Adhere to HIPAA regulations and maintain patient confidentiality.

Additional Responsibilities:
Effectively communicate and collaborate with other departments to implement best practices while accurately complying with healthcare regulations and guidelines.
Assist in the setup and maintenance of provider information in online credentialing databases and systems.
Support the maintenance of corporate provider contract files.
Exhibit integrity and commitment to the mission and values of the organization.
Perform other duties as assigned by Revenue Cycle Leadership.


Maintain a focus on quality and compliance in all aspects of the role.


Reports to:
Senior Revenue Cycle Manager

Qualifications:

Education/Professional:

  • Bachelor's degree in healthcare, business, finance, or equivalent healthcare experience (3 years minimum).
  • A minimum of three to five years of credentialing coordination experience is required.

Knowledge, Skills, and Abilities Required:

  • Ability to work independently with minimal supervision.
  • Experience with medical payers, including Medicare, Medicaid, commercial, and third-party administrators.
  • Strong attention to detail and accuracy in data entry and record-keeping.
  • Excellent written and verbal communication and interpersonal skills.
  • Proficient in Microsoft Office (Excel, Visio, Word, PowerPoint) and adept at using Internet resources.
  • Strong people skills, open to direction, and committed to completing tasks efficiently.
  • Promotes teamwork, productivity, and the delivery of high-quality care.
  • Comfortable working in a diverse environment with changing priorities.

Physical Requirements:
Requires frequent bending, stooping, and standing. Requires visual and auditory acuity, frequent sitting, and walking for extended periods.


CAN is an equal opportunity employer committed to diversity and values the unique contributions of all individuals.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Remote working/work-from-home options are available for this role.