Provider Credentialing Specialist I

3 weeks ago

Owings Mills, United States CareFirst BlueCross BlueShield Full time

PURPOSE:


This role will credential dental practitioners for network participation with CareFirst BlueCross BlueShield and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area home. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business related activities.

ESSENTIAL FUNCTIONS:

Analyzes credentialing applications to perform the primary source verification of the appropriate credentials for a dental practitioner to participate in the CareFirst networks. Once verified, accepted, and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.

Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, contractual status, and provider file updates. Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing and data integrity are achieved. Professional etiquette, communications and sound decision making is required.

Maintains the provider file, the provider information inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations, and all other provider file maintenance activities.

Responsible for identifying, analyzing, and resolving immediate and existing provider file issues through telephone calls, email, and system routes from operational areas. Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered the provider file database, ensuring a successful integration with the other corporate systems.

Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

QUALIFICATIONS:

Education Level:  High School Diploma

Licenses/Certifications Preferred:

Certified Provider Credentialing Specialist (CPCS) 

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

Preferred Qualifications:

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

Knowledge, Skills and Abilities (KSAs)

Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables. Excellent verbal and written communication and interpersonal skills. Ability to develop and maintain effective relationships with peers, dentists, physicians, and medical staff to create confidence, respect, and dependability. Demonstrated proficiency utilizing reference materials and ability to follow Standard Operating procedures to reduce risk and ensure provider data accuracy and overall quality. Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes and interpret reasoning for performing verification and/or appropriate actions. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Department

Department: 

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

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