Credentialing Specialist
6 days ago
- Maintain communication with facilities and provider sites to coordinate receipt of information required for credentialing, re-credentialing, and update of provider credentialing information.
- Review provider re-credentialing and credentialing file for completion and presentation to the Credentialing Committee.
- Perform primary source verification on required elements and in accordance with regulatory guidelines and policies and procedures.
- Data entry and upkeep of provider information in the credentialing and other pertinent databases.
- Verify New York State OPMC, Medicare/Medicaid lists and other pertinent databases for any current sanctions, restrictions on licensure and/or limitations on the scope of practice on all credentialed providers in interim credentialing periods.
- Verify New York State license registration and DEA registration status for all credentialed providers in the interim credentialing periods.
- Generate and disseminate monthly provider credentialing updates to appropriate departments and participating facilities and provider groups.
- Review and respond to requests for credentialing information/copies of credentialing files to appropriate departments.
- Generate and disseminate provider rosters to delegated facilities, contracted group practices, etc.
- Perform provider roster reconciliation.
- Create, copy, file, and maintain all relevant documentation into provider credentialing folder.
- Maintain confidentiality of provider credentials by filing the credentialing folder in respective cabinets in the file rooms.
- Perform annual delegated file audits and participate in pre-delegation and delegation site reviews.
- Respond to inquiries from other departments relative to a provider's credentialing status.
- Perform other related tasks as directed by the Deputy Chief Operating Officer or her designee, the Credentialing Director or Credentialing Team Lead.
- High school degree required; Bachelor's degree preferred.
- 2 years of previous experience with provider credentialing processes and procedures.
- Knowledge of CACTUS or MD-Staff preferred.
- Must be able to handle multiple projects simultaneously.
- Comprehensive knowledge of managed care with a specific emphasis on physician credentialing.
- Ability to meet time-sensitive deadlines and multi-task in a changing healthcare environment.
- Understanding of credentialing activities as they relate to initial credentialing, re-credentialing, and credentials modification(s).
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