OFFICIAL JOB STANDARDS
Job Title: Credentialing Specialist
Company: Secure Health Plans
Type of Business: Managed HealthCare Organization
Department: Provider Relations
Supervisor: Provider Relations Director
What are the major objectives or outcomes to be accomplished by the person in this job?
- Responsible for the credentialing and recredentialing activities for Secure Health Plans of Georgia, LLC (SHPG) network providers in accordance with the NCQA credentialing standards and guidelines, as well as ensuring that these activities meet federal and state guidelines.
- Serve as back-up to the Provider Maintenance Specialist and Provider Relations Representative, as needed.
What are the most frequent and most essential work activities in this job?
- Administers/Coordinates/Manages the daily workflow of credentialing and recredentialing applications with proficiency, accuracy and timeliness.
- Maintains close communication with the Local Provider Organization (LPO) representatives, and other network Provider Relations staff.
- Coordinates the enrollment of providers with LPO’s and other health care plan providers.
- Performs primary source for verification and reference checks required for both new applications and reappointments.
- Maintains current information in provider credentialing files to assure compliance with Secure Health policies and procedures, bylaws, rules and regulations, as well as all relevant/applicable accreditation agencies.
- Maintains and updates data entry for all providers in applicable provider database, in conjunction with other PR staff members, providing reports as requested.
- Coordinates the workflow of provider updates, relative to state licensure, DEA certification and malpractice professional liability expirations; tracking each at a frequency minimum of at least monthly.
- Coordinates with Director of Provider Relations to develop Marketing & Finance pre-app listing for scheduled, quarterly meeting. Serves as staff support for all Credentials Committee meetings, coordinating with Provider Relations Director and other PR staff members in the development of the final meeting packet and committee minutes
- Assists in the coordination and development of quarterly provider newsletter
- Performs site visits for provider office locations in the credentialing and recredentialing process within the timeframe designated by all applicable accreditation standards.
- Coordinates with other PR staff members to perform complete file audits on all provider files prior to submission to the Credentials Committee for credentialing and recredentialing decision.
- Clerical duties including faxing, filing, copying, etc.
- Performs other duties as assigned.
What behavioral traits, attitudes and skills are required?
- Knowledge and understanding of the credentialing process.
- Ability to research and analyze data.
- Ability to work independently with minimal supervision.
- Proficiency in Microsoft Office (Excel, Access and Word) and internet resources.
- The ability to work under stress.
- The ability to follow instructions and maintain precise and intense attention to detail.
- Knowledge of relevant state and federal laws and regulations relative to network credentialing, as well as all applicable accreditation standards (e.g., NCQA and/or URAC)
- Ability to research and apply applicable Board Certification criteria for all applicable Specialty Boards, for both medical and allied health providers
- The ability to exercise judgment and discretion in interpreting and applying policies and procedures.
- The ability to communicate and work effectively with co-workers, provider office staffs, and committee members. Also must have the ability to communicate clearly, concisely and effectively with different audiences and possess excellent verbal and written skills.
- Ability to compose and prepare accurate reports, records, and correspondence.
- Excellent time management skills, organization skills and people skills.
- Ability to be a self-starter, be self-motivated, and the ability to manage multiple projects.
- Ability to be structured, yet flexible and open to new ideas.
- Have an understanding of different fee arrangements, networks and managed care products.
- Examines, researches, enters data, files, and gather information necessary to process information received to support the credentialing process.
- Verify, research and respond to telephone and email inquiries pertaining to provider’s credentialing status in a professional and courteous manner.
What are the prerequisites for employment?
- A college degree or equivalent training preferred.
- At least four years previous experience, including a minimum of two years of direct credentialing experience in medical staff or managed care credentialing, preferred.
- Knowledge of Georgia laws, the Medical Practice Act, the National Committee for Quality Assurance (NCQA) Credentialing Standards and Guidelines, American Accreditation Healthcare Commission / URAC, and Joint Commission on Accreditation of Healthcare Organizations requirements regarding managed care providers.
- Knowledge of medical terminology, business English, spelling and commercial arithmetic.
- Knowledge of computers and other standard office machines and equipment.
- Experience in claims processing and/or member services dealing with fee schedules and facility arrangements, preferred.
- Experience in provider maintenance, provider relations and/or related fields.
- Experience in working with a managed care computer system to input data and with Excel spreadsheets and Access databases.
Interested applicants should email their résumé and cover letter to firstname.lastname@example.org.