Credentialing Specialist

Job Summary:

The Credentialing Specialist is responsible for coordinating initial and re-credentialing applications for network dentists, ensuring compliance with standards and regulatory requirements. This role involves maintaining accurate provider data, managing provider directories, and serving as a point of contact for provider offices and leased networks.

Location:

Evansville, Indiana, United States

Responsibilities:

- Gather, verify, track, and maintain an audit trail of all elements outlined in the Plan's credentialing and re-credentialing policies and procedures.
- Provide administrative support for credentialing and re-credentialing, including preparing accurate correspondence and reports related to provider applications.
- Maintain working knowledge of credentialing and re-credentialing standards and communicate with the Dental Review Team as needed for application review.
- Manage provider contracts and fee schedules.
- Ensure dentist files are current with licensure, DEA certificates, malpractice insurance coverage, malpractice claims history, and National Practitioner Data Bank requirements.
- Run quarterly provider adequacy and accessibility reports.
- Maintain Commercial and Medicare provider directories.
- Upload updated provider directories to Medicare and health plans monthly.
- Complete network verification to meet state requirements.
- Process provider updates in the system and notify providers upon completion.
- Support accounting with TIN verification as needed.
- Process member letters related to provider terminations.
- Serve as a direct contact for provider offices requesting verification or additional information.
- Act as the primary contact for leased networks, including requesting reports and provider data.

Required Skills &

Certifications:

- 3+ years of provider credentialing experience
- Tech-savvy with credentialing software and Excel
- High School Diploma or GED
- Prior insurance industry knowledge

Preferred Skills &

Certifications:

- None specified

Special Considerations:

- This is an onsite role.
- Dress code is business casual.
- Covering a Leave of Absence (LOA) with potential for temp-to-perm.
- The organization uses CAQH and NPDB for credentialing data.

Scheduling:
- Not specified