Credentialing Specialist

21 hours ago


Bowling Green, Kentucky, United States Molina Healthcare Full time
Job Title: Credentialing Specialist

Molina Healthcare is seeking a highly skilled Credentialing Specialist to join our team. As a Credentialing Specialist, you will play a critical role in ensuring that our provider network meets all regulatory and risk management criteria.

Job Summary

The Credentialing Specialist will be responsible for the initial credentialing, recredentialing, and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations. This includes evaluating credentialing applications for accuracy and completeness, communicating with healthcare providers, and updating credentialing software systems.

Key Responsibilities
  • Evaluate credentialing applications for accuracy and completeness, and obtain required verifications as outlined in Molina policies and procedures.
  • Communicate with healthcare providers to clarify questions and request any missing information.
  • Update credentialing software systems with required information.
  • Request recredentialing applications from providers and conduct follow-up on application requests.
  • Collaborate with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
  • Complete data corrections in the credentialing database necessary for processing of recredentialing applications.
  • Review claims payment systems to determine provider status, as necessary.
  • Complete follow-up for provider files on 'watch' status, as necessary.
  • Review and process daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
  • Review and process daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.
  • Review and process daily NPDB Continuous Query reports and take appropriate action when new reports are found.
Requirements
  • High School Diploma or GED.
  • Experience in a production or administrative role requiring self-direction and critical thinking.
  • Extensive experience using a computer, specifically internet research, Microsoft Outlook, and Word, and other software systems.
  • Experience with professional written and verbal communication.
Preferred Qualifications
  • Experience in the healthcare industry.
What We Offer

Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $29.06/HOURLY



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