Credentialing and Contracting Medical Provider Network Specialist

Job DetailsLevel
Experienced

Job Location
Fresno Office - Fresno, CA

Remote Type
Hybrid

Position Type
Full Time

Education Level
High School Diploma or GED

Salary Range
$17.00 - $19.00 Hourly

Travel Percentage
20%

Job Shift
Day

Job Category
Insurance

Credentialing & Contracting Medical Provider Network SpecialThis will be a remote position in Fresno, CA. The possible travel will be to attend in-office meetings and office events.JOB SUMMARY:

The Credentialing and Contracting Specialist is responsible for preparing and maintaining contracts and the contracts database system. Maintain active status for all providers by successfully completing initial and subsequent credentialing packages as required by state regulations, guidelines and policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, the employee must be able to efficiently and effectively perform each of the following essential functions. Reasonable accommodation may be made for individuals with disabilities.

The functions of this job include but are not limited to;

• Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with regulations, guidelines, policies, and standards. Monitors Applications and follows-up as needed.
• Conducts primary source verification, collects and validates documents (state license, DEA Certificates, malpractice coverage, etc.) to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards to ensure timely renewal. Maintains provider contract files.
• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to Director for sound decision making in accordance with credentialing policies and procedures, state regulations.
• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
• Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
• Participates in the development and implementation of process improvements for the credentialing process.
• Communicates clearly with providers, their liaisons, and staff as needed to provide timely responses upon request on day-to-day credentialing, provider, staff and client issues as they arise.
• Assist in helping find available physician(s) when unavailable within the Network.
• Maintains professional growth and development through professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
• Performs miscellaneous job-related duties as assigned.

• Ability to communicate effectively both orally and in writing.
• Customer service skills.
• Ability to respond to emails timely and effectively.
• Information research skills.
• Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications.
• Ability to make administrative/procedural decisions and judgments.
• Demonstrated advanced working knowledge of Microsoft Word and Excel.
• Ability to learn new applications to function effectively in a remote work environment.
• Skill in establishing priorities with independent coordination of day-to-day aspects.
• Skills in computerized spreadsheets and database management.
• Ability to organize and prioritize work and manage multiple priorities.

1. EDUCATION and/or EXPERIENCE:

• High school diploma or equivalent required.
• Computer skills required with knowledge in utilizing Outlook, Microsoft Word, Excel and other databases.

1. LANGUAGE SKILLS

• Extensive clear, professional and tactful communications required via writing, reading, telephone calls, note taking, letter writing, memoranda, etc. Must be able to follow instruction and pay close attention to detail.

1. PHYSICAL DEMANDS

• The physical demand described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is regularly required to sit, talk and hear.
• The employee frequently is required to use hands to operate a computer keyboard, handle or feel and reach with hands and arms.
• The employee is occasionally required to stand and walk.
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• The employee must frequently be able to communicate clearly in person or over the phone.
• No or very limited exposure to physical risk.
• Work is normally performed in a typical interior/office work environment.

1. WORK ENVIROMENT

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually quite

• Medical, Dental, Vision, Disability & Life Insurance
• 401(k) plan
• Paid time off.
• Paid holidays.