Provider Credentialing Specialist

1 week ago

Baltimore, Maryland, United States TalTeam Full time

Job Description:

OBJECTIVE:

This position is responsible for the credentialing of healthcare practitioners for network inclusion and for the accurate upkeep of all provider information within the comprehensive Provider database. This ensures the organization has reliable provider data while adhering to regulatory, accreditation, legal, and corporate standards.


KEY RESPONSIBILITIES:

40% Evaluates credentialing submissions to conduct primary source verification of the necessary credentials for practitioners to join the networks. Upon verification, acceptance, and approval, identifies suitable networks for participation and secures the necessary executed agreements to formalize the professional relationship, structuring the provider group accordingly.

30% Addresses inquiries from both external and internal stakeholders regarding provider eligibility and criteria, participation status, credentialing processes, contractual conditions, and updates to provider files. Focuses on enhancing the provider experience by ensuring timely resolutions, dependable follow-ups, and proactive measures to achieve successful credentialing.

15% Maintains the provider database, the Provider Information Control (PICS) inventory management system, and electronic provider records with updated information throughout processes such as credentialing, recredentialing, demographic modifications, terminations, and all other provider file maintenance tasks.


10% Identifies, analyzes, and resolves immediate and ongoing provider file issues. Processes provider file inputs in compliance with relevant state regulations and departmental guidelines. Verifies provider data and oversees system releases entered into the provider file database, ensuring successful integration with other corporate systems.


5% Prepares written communications to request incomplete or missing information and communicates effectively via telephone.


Qualifications:

To excel in this role, an individual must successfully perform each essential duty. The requirements outlined below represent the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to fulfill the essential functions.


Education:
High School Diploma

Experience: Minimum of 3 years in physician credentialing or health insurance/managed care operations experience in customer service, claims, billing and enrollment, or call center environments.


Preferred Qualifications:

Bachelor's Degree in Business, Healthcare Administration, or a related field.


Knowledge, Skills, and Abilities (KSAs):

Proficient in Excel spreadsheets, including an understanding of Pivot tables. Excellent verbal and written communication skills, with the ability to build and maintain effective relationships with peers, physicians, and medical staff to foster trust and reliability. Knowledge of medical terminology is essential.

Demonstrated ability to utilize reference materials and adhere to Standard Operating Procedures to minimize risk and ensure the accuracy and quality of provider data.

Ability to comprehend jurisdictional requirements and the legal implications of the credentialing and provider file maintenance processes, interpreting the rationale for performing verifications and/or necessary actions.


Licenses/Certifications:
Certified Provider Credentialing Specialist (CPCS) Preferred

Talteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

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