Provider Network Credentialing Specialist
7 days ago
At Health First, we are seeking a highly skilled and detail-oriented Provider Network Credentialing Specialist to join our team. As a key member of our credentialing team, you will play a critical role in ensuring that our healthcare providers meet the necessary requirements for credentialing and re-credentialing.
Key Responsibilities:- Credentialing and Re-Credentialing: Coordinate, monitor, and maintain the credentialing and re-credentialing processes of healthcare providers and practitioners to ensure compliance with Health Plan credentialing policies and regulatory agencies.
- Reporting and Data Integrity: Provide accurate and timely reports to internal departments for annual projects/audits, such as HEDIS Roadmap, QI Credentialing Evaluation, and Finance. Ensure precise entry of provider information to maintain accurate provider directories and overall data integrity.
- Primary Source Verification: Conduct primary source verification on applicants, including requests, investigations, verifications, tracking, and follow-up of primary responses from required sources.
- Liaison and Communication: Act as liaison with providers and facilities to assist with credentialing issues, ensure demographic information is received and entered correctly, and communicate with providers on the status of their credentialing and any findings during the process.
- Monitoring and Quality Improvement: Conduct ongoing monitoring of practitioners and organizational providers to identify important quality and safety issues in a timely manner.
- Confidentiality and Compliance: Manage confidential files on all credentialed practitioners and organizational providers, and ensure compliance with Health First's credentialing policies and procedures.
- Accreditation and Regulatory Compliance: Use web-based tools to oversee AHCA site visits and findings, as well as accreditation status for organizational providers.
- Provider Network Adequacy: Conduct reviews of provider network adequacy for quality improvement evaluation, meeting standards to the Centers for Medicare & Medicaid Services Central and Regional Offices, and the Office of Insurance Regulation.
- Provider Term Letters and Communication: Participate in the provider term letter process, including member communication related to provider terminations.
- Credentialing Information Source: Serve as a credentialing information source for Health First and Health First Health system.
- Provider Directory Accuracy: Conduct Provider Directory accuracy audits and participate in meetings, projects, and sub-teams related to the Provider Directory to ensure provider information is accurate.
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