SUMMARY: The Credentialing Specialist provides multiple services for the credentialing program, including the initial review of applications, the management of recredentialing files, the creation and management of appropriate primary and secondary source verifications, the compilation of practitioner data, and the maintenance of databases/spreadsheets to support operational tracking needs.

The Credentialing Specialist position requires independent business decisions to be made regarding the status of the completion of the credentialing files, prior to submission. The Credentialing Specialist assures that negative findings are reported as such, and documentation is maintained on these findings, to assure quality checks are handled appropriately at the time of the findings, as well as throughout the practitioners’ cycles.

ESSENTIAL FUNCTIONS: Evaluation

Process credentialing and re-credentialing applications for Agency with MCOs and health care providers.

Follow-up on submitted paperwork and review of information before issuance of contracts with MCOs.

Contact medical staff, licensing agencies and insurance carriers to complete credentialing and re-credentialing applications.

Submit all appropriate and required data to third party billing.

Enroll Agency and clinical staff with Medicare and Medicaid; maintains carrier enrollment updated.

Maintain group and individual provider files. Maintains COO and Chief Human Resources Officer of problems with physicians and clinical staff credentialing files.

Enter/update credentialing data and provider number in internal system as approved/received.

Copy and assemble new group/physicians packets; type enrollment and deletion letters; submit group/individual enrollment packet to management or individual physicians for signature; maintain copies of submitted data to management, physicians and carriers; maintain copies of correspondence to and from physicians and carriers.

Creates credentialing files for staff and managed care organizations. Inform clinical staff of issues or problems pertaining to enrollment.

Maintains COO informed of any issues related to enrollment difficulties and length of process for each carrier.

On a monthly basis, compile data and prepare reports/rosters for distribution to all MCOs and AHCA.

At least twice a year, verifies the professional license of employees. Compile reports on licensed employees and notifies employees for license/credentials renewals.

Register medical staff CAQH.

Register clinical staff with Databank.

Register clinical staff with the National Provider Identifier and the NPDB

Ensure employee requiring privileging rights, the same are obtained and board approved prior to the employee joining the Agency.

Performs all other duties as assigned.

Average Rating

NON-ESSENTIALS FUNCTIONS: None noted at this time.

SUPERVISORY RESPONSIBILITIES: None noted at this time.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE: High School Diploma; Associate’s Degree preferred, not required. Two- (2) years of current managed care credentialing experience, preferred.

LANGUAGE SKILLS: Ability to read, write and speak in English and Spanish (or other languages) helpful. Must be able to read and comprehend simple instructions, short correspondence, and memorandums. Agility to effectively communicate information both orally and written on one-to-one and small group situations to clients and other employees.

MATHEMATICAL SKILLS: Ability to add, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio and percent.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

ORGANIZATIONAL SKILLS: Must be organized and able to schedule work load appropriately without hindrance to client appointments etc.

DECISION MAKING: Must be able to work independently with competent decision making using established criteria and guidelines.

OTHER SKILLS AND ABILITIES: Computer Skills: To perform this job successfully, an individual should have knowledge of Accounting software; Database software; Internet software and Word Processing software.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; and talk or hear. The employee is frequently required to stand, walk and reach with hands and arms. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORK ENVIROMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

SAFETY: Follows the general guidelines of the Agency to promote and maintain a safe working environment.

Job Type: Full-time

Pay: $11.31 - $22.23 per hour

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Miami, FL 33126: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Microsoft Office: 1 year (Preferred)
• Microsoft Word: 1 year (Preferred)

Work Location: In person

Please Note :
dgeus.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, dgeus.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.