Job Description
Responsibilities and Qualifications:
Credentialing and Recredentialing Process: Process credentialing/recredentialing applications in a timely manner and meet production standards of work unit by volume in accordance with the prevailing credentialing unit production timelines. Be able to transition between processing initial credentialing and recredentialing applications when the manager requests. Process all credentialing/recredentialing applications with a 98% accuracy rate. QC the processed credentialing files against NCQA, CMS and DOH regulations resulting in error reports on a monthly basis. Analyze application materials to assure that providers meet NCQA, CMS and Plan criteria and, as appropriate, obtain verification information from external sources such as the State Board of Licensure, appropriate board certification agencies, hospitals, medical schools, the Drug Enforcement Agency, and the National Practitioner Databank. Present to the Manager and and/or Credentialing Coordinator complete and accurate information on a provider that is going to the Pre-Credentialing Committee Meeting as an “issue.” All information must be presented to the Manager and/or Credentialing Coordinator by the Friday before a Pre-Credentialing Meeting Recommend quality improvement to enhance workflow and to increase overall performance and increase efficiencies.
Data Management, Integrity and Quality: Review the source document/application for complete and accurate information. Maintain integrity of provider data through ongoing monitoring and updates to provider information in the provider credentialing software. Interface with practitioners, office managers, etc. regarding questions or issues with source document information/application.
Job Knowledge: Maintains an in-depth understanding of NCQA Guidelines. Maintains an in-depth knowledge of how credentialing files are maintained in Cactus. Maintains an in-depth understanding of the different credentialing criteria needed to credential/recredential a provider and assess and reassess a facility.
Technical and Administrative Support: Facilitate or assist in the assessment and reassessment of facilities. Process DCV files received by delegates entities in a timely manner. Oversee/Perform annual oversight NCQA file audits with delegates’ entities. Build queries in Cactus to create reports as needed. QC completed processed credentialing and recredentialing files. Identify, research, and resolve technical and operation issues. (Including with outside vendors such as Cactus and CAQH). Review and primary source verify all medical licenses and certifications (new and expired licenses and certifications) for employees per Credentialing Policy and Procedures (Monthly). Review and primary source verify all Capital Clinical Staff Employees licenses, DEA and board certification. Review PA, MD and NJ’s Medical Licenses sanctions on a monthly basis. Gather all the needed information on all providers that are participating with Capital and are appearing on the sanction reports and reports sanction information to the Manager for possible presentation to the Credentialing Committee.
Skills:
Team player, good interpersonal skills, dependable
Detail oriented, ability to multitask, be able to work independently and as team, demonstrate ability to effectively communicate both verbally and written, demonstrate research and analytical skills, be able to maintain focus for long periods of time. Ability to take direction from and perform project support work for various levels of staff.
Knowledge:
Credentialing and Recredentialing Process: Process credentialing/recredentialing applications in a timely manner and meet production standards of work unit by volume in accordance with the prevailing credentialing unit production timelines. Be able to transition between processing initial credentialing and recredentialing applications when the manager requests. Process all credentialing/recredentialing applications with a 98% accuracy rate. QC the processed credentialing files against NCQA, CMS and DOH regulations resulting in error reports on a monthly basis. Analyze application materials to assure that providers meet NCQA, CMS and Plan criteria and, as appropriate, obtain verification information from external sources such as the State Board of Licensure, appropriate board certification agencies, hospitals, medical schools, the Drug Enforcement Agency, and the National Practitioner Databank. Present to the Manager and and/or Credentialing Coordinator complete and accurate information on a provider that is going to the Pre-Credentialing Committee Meeting as an “issue.” All information must be presented to the Manager and/or Credentialing Coordinator by the Friday before a Pre-Credentialing Meeting Recommend quality improvement to enhance workflow and to increase overall performance and increase efficiencies.
Data Management, Integrity and Quality: Review the source document/application for complete and accurate information. Maintain integrity of provider data through ongoing monitoring and updates to provider information in the provider credentialing software. Interface with practitioners, office managers, etc. regarding questions or issues with source document information/application.
Job Knowledge: Maintains an in-depth understanding of NCQA Guidelines. Maintains an in-depth knowledge of how credentialing files are maintained in Cactus. Maintains an in-depth understanding of the different credentialing criteria needed to credential/recredential a provider and assess and reassess a facility.
Technical and Administrative Support: Facilitate or assist in the assessment and reassessment of facilities. Process DCV files received by delegates entities in a timely manner. Oversee/Perform annual oversight NCQA file audits with delegates’ entities. Build queries in Cactus to create reports as needed. QC completed processed credentialing and recredentialing files. Identify, research, and resolve technical and operation issues. (Including with outside vendors such as Cactus and CAQH). Review and primary source verify all medical licenses and certifications (new and expired licenses and certifications) for employees per Credentialing Policy and Procedures (Monthly). Review and primary source verify all Capital Clinical Staff Employees licenses, DEA and board certification. Review PA, MD and NJ’s Medical Licenses sanctions on a monthly basis. Gather all the needed information on all providers that are participating with Capital and are appearing on the sanction reports and reports sanction information to the Manager for possible presentation to the Credentialing Committee.
Skills:
Team player, good interpersonal skills, dependable
Detail oriented, ability to multitask, be able to work independently and as team, demonstrate ability to effectively communicate both verbally and written, demonstrate research and analytical skills, be able to maintain focus for long periods of time. Ability to take direction from and perform project support work for various levels of staff.
Knowledge:
💡 Quick Summary
Seeking a career-building opportunity? The Credentialing Specialist II position is now open for candidates interested in the Work from home Jobs sector. This role in Bideford offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Work from home Jobs is a plus.