Delegated credentialing specialist i - managed care - days - ft

The Delegated Credentialing Specialist I is responsible for assisting in credentialing with the appropriate delegated insurance plans, governmental agencies and any other participating insurance plans. The Specialist I provides support in processes related to the preparation and processing of information and monitors compliance with regulatory and accrediting bodies as well as delegated rules and regulations. The Specialist I maintains accurate and up to date data within the relevant databases.

RESPONSIBILITIES

• Provides support in compiling and completing physician and provider credentialing forms for appropriate payor delegations
• Aids in the verification and documentation processes for submitted applications
• Assists with the completion of physician and provider participating contracts and credentialing files
• Collaborates with insurance plan providers and representatives to obtain and complete specific payer credentialing forms and applications
• Participates in preparing and providing information to various departments and external entities
• Communicates with appropriate billing staff regarding the status of a provider's enrollment with individual payers
• Facilitates provider-related research based on suspended claims, denial issues related to the enrollment process and other feedback opportunities
• Provides requested information to authorized agencies for audits and reviews
• Ensures compliance with delegation monitoring and oversight requirements for credentialing functions
• Collaborates with the various departments to conduct the timely credentialing delegation audits
• Participates in post-audit results meetings with insurance representatives and contributes to the resolution of any audit findings
• Attends provider onboarding to obtain additional information/signatures from providers
• Maintains and updates physicians and provider information in the applicable databases
• Maintains credentialing database and provider billing number tracking sheet
• Monitors and tracks license and certification expirations and renewals and provider information
• Maintains physician and provider directory information for departments and hospital
• Performs tracking and follow-up to ensure provider numbers are linked to appropriate entity and location

QUALIFICATIONS

Education:

Required

• High School or GED

Licensure or Certification Requirements:

Preferred

• Certified Provider Credentialing Specialist (CPCS) from the National Association of Medical Staff Services

Experience:

Required

• 1 year of experience with payor credentialing or related

Skills:

• Strong verbal and written communication skills
• Data entry with minimal errors
• Seeking solutions using appropriate methodologies