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Provider Network Credentialing Specialist

2 months ago

Rockledge, Florida, United States Health First Full time
Job Summary

The Provider Network Credentialing Specialist plays a critical role in ensuring the credentialing and re-credentialing processes of healthcare providers and practitioners meet the requirements of Health First's credentialing policies and regulatory agencies, including the National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS) standards.

Key Responsibilities
  1. Coordinate and monitor the credentialing and re-credentialing processes to ensure compliance with Health First's policies and regulatory requirements.
  2. Provide reports to internal departments for annual projects/audits, such as HEDIS Roadmap, QI Credentialing Evaluation, and Finance, as well as reports for the Medical Director, Credentialing Committee, and the Board of Trustees.
  3. Perform precise entry of provider information to ensure accurate provider directories and overall data integrity.
  4. Conduct primary source verification on applicants, which may include requesting, investigating, verifying, tracking, and following up on primary responses from required sources as per Health First's credentialing policies and procedures.
  5. Act as liaison with providers and facilities to assist with credentialing issues and ensure demographic information is received and entered correctly, while communicating with providers on the status of their credentialing and any findings during the process.
  6. Conduct ongoing monitoring of practitioners and organizational providers to identify important quality and safety issues in a timely manner.
  7. Manage confidential files on all credentialed practitioners and organizational providers.
  8. Use web-based and other available tools to oversee AHCA site visits and findings, as well as accreditation status for organizational providers.
  9. Conduct reviews of provider network adequacy for quality improvement evaluation, meeting standards to the Centers for Medicare & Medicaid Services Central and Regional Offices, as well as the various departments within the Office of Insurance Regulation for service area expansion efforts, as needed.
  10. Participate in the provider term letter process, including all member communication related to provider terminations.
  11. Serve as credentialing information source for Health First and Health First Health system.
  12. Conduct Provider Directory accuracy audits and participate in any meetings, projects, and sub-teams related to the Provider Directory to ensure provider information is accurate for the Provider Directory.
Requirements
  • Education: Associate's degree.
  • Licensure: None.
  • Certification: None.
  • Work Experience: Two years' experience with physician and/or organizational credentialing processes.
  • Work Experience in lieu of Education: None.
  • Knowledge/Skills/Abilities: Exceptional interpersonal, communication, and organizational skills; excellent organization skills required; advanced technical skills for use of MS Office (Excel, Word, Outlook, and PowerPoint); strong time-management skills; high degree of accuracy, efficiency, and dependability.