Credentialing Specialist

WHAT DOES A CREDENTIALING SPECIALIST DO?

Updated:
Jan 12, 2025 - The Credentialing Specialist updates and maintains provider data within a database, promptly escalates issues for resolution, and reports on project progress. This role involves compiling and processing credentialing applications, ensuring compliance with health plan and regulatory requirements, and maintaining confidentiality in line with HIPAA guidelines. Meetings with Credentialing Leadership, inter-departmental coordination, and documentation of processes are integral parts of the position.

• Application Updates:
  Assist team with application updates in the database.
• Issue Escalation:
  Escalate issues with the database as identified for prompt resolution.
• Progress Reporting:
  Report progress routinely to management to ensure projects are completed successfully.
• Credentialing Applications:
  Completing and processing provider credentialing applications.
• Data Management:
  Compiling and maintaining current and accurate data for all providers.
• Regulatory Knowledge:
  Maintaining knowledge of current health plan and agency requirements for credentialing providers.
• Verification Provision:
  Providing credentialing and privileging verifications if applicable.
• Confidentiality Adherence:
  Maintaining strict confidentiality and adhering to all HIPAA guidelines/regulations.
• Meeting Attendance:
  Attend meetings scheduled with Credentialing Leadership, other Next Care Departments, and health plan representatives.
• Process Documentation:
  Document processes and procedures.
• Mission Alignment:
  Treat patients and co-workers consistent with the Next Care Mission Statement, Vision, Values, and Performance Standards.
• Team Assistance:
  Assist other members of the team.
• CAQH Maintenance:
  Initiate and maintain CAQH files on all providers.

• Primary Source Verification:
  Perform primary source verification on all providers.
• Credentialing Applications:
  Complete and submit credentialing applications for both providers and facilities.
• File Maintenance:
  Maintain files with provider and facility credentials.
• Billing Information:
  Obtain and supply information to correctly bill services.
• Information Tracking:
  Track information and submit timely.
• Application Coordination:
  Coordinate with Credentialing Representative I to update primary source applications every two years.
• Re-Credentialing:
  Complete any re-credentialing applications for providers.
• Group Applications:
  Complete and submit group applications for new locations or re-credentialing.
• Notification Submission:
  Submit notification letters to plans for new locations or updates to facilities.
• Team Assistance:
  Assist other members of the team.
• CAQH Maintenance:
  Initiate and maintain CAQH files on all providers.

• Credentialing Processing:
  Process health plan enrollment/credentialing applications for physicians and allied health providers.
• Paperwork Review:
  Review and analyze the provider’s returned paperwork to ensure the completeness of the information.
• Issue Identification:
  Identify and flag adverse information received from materials completed by the provider for the purpose of conducting a special investigation.
• Reporting:
  Report this information to the Credentialing Specialist for follow-up.
• Follow-up System Maintenance:
  Maintain tickler system outside of the credentialing database for follow-up of outstanding paperwork and unanswered correspondence according to schedules designed to maintain department standards for application processing time.
• Report Generation:
  Run weekly reports from the credentialing database to determine required follow-up with providers and health plans.
• Data Entry:
  Enter contact and action notes into a credentialing database to maintain an accurate record of progress with health plans.
• Database Maintenance:
  Maintain credentialing database and billing database, updating provider health plan identification numbers and other required database fields.
• File Organization:
  Organize and maintain provider health plan files and information…