Credentialing specialist

In this role, the Credentialing Specialist will be responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities and maintain up-to-date data for each provider in credentialing databases and online systems, ensuring timely renewal of licenses and certifications. Understands CMS Medicare, Medicaid, and managed care billing, credentialing and enrollment requirements and reimbursements methodologies and applies knowledge to identify, quantify, and address missing/incorrect charges. Assist in the development of resources for researching issues.

ESSENTIAL FUNCTIONS:

Screening practitioners applications and supporting documentation to ascertain their eligibility.

Identifying discrepancies in information and conducting follow-ups.

Medicare & Medicaid enrollment and revalidation.

Processing initial credentialing and re-credentialing applications with follow up to ensure that credentialing is completed, and providers enrolled in health plan products.

CAQH profile creation.

Maintenance of internal and external databases (CAQH, PECOS, NPPES).

Initial and reappointment of hospital privileges.

Assisting internal customers with credentialing inquiries.

Actively participates in group leadership meetings and is accountable for presenting credentialing status for all groups.

Coordinates and facilitates troubleshooting with payer networks to resolve any issues related to enrollments.

Experience in contract negotiations is beneficial.