PURPOSE AND SCOPE:
The Credentialing Specialist is responsible for verifying submitted Credentialing documentation. for all specialties that provide services to the organization's members. The Credentialing Specialist incumbent will meet all credentialing turnaround time levels by submitting accurate and complete applications. The Credentialing Specialist will abide by all policies and processes to meet all state, regulatory, health/safety, and compliance guidelines.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Verifies and reviews all related specialty credentials, including but not limited to Medicare, education, training, licenses, and malpractice/professional liability insurance, CLIA licensure, facility surveys, as applicable.
- Enters all provider information and primary source verification data into the related database.
- Creates and maintains provider files in compliance with the organization's policies.
- Completes payer enrollment and/or facility applications in a timely and complete manner consistent with Department goals and metrics.
- Responsible for outreach to pertinent parties to obtain any needed documents that go along with credentialing applications as directed.
- Escalates any missing items as directed to leadership in efforts to stay on task and avoid credentialing lapses
- Abides by all policies, procedures, and work instructions for the credentialing function,
- Assists in goals and performance standards management.
- Ensures data integrity is maintained in related credentialing database and core system records.
- Improves efficiencies and service provided while reducing costs.
- Obtains DUNS number and complete online application process in SAMS to ensure the DUNS number is activated
- Completes yearly revalidations and other requests regarding the DUNS number in SAMS to ensure correct information is loaded in the system to avoid delays in payment and obtaining authorizations
- Attends trainings and references training materials including content, work instructions, and tools, as required
- Obtains knowledge of credentialing regulatory and accreditation requirements (CMS, NCQA, etc.).
- Performs monthly monitoring of expirations.
- Performs quality checks.
- Assists with various projects as assigned by direct supervisor.
- Performs other duties as assigned.
PHYSICAL DEMANDS AND WORKING CONDITIONS:
- The physical demands and 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.
- Little to no travel is required.
SUPERVISION:
EDUCATION:
- High School Diploma required
EXPERIENCE AND REQUIRED SKILLS:
- 2-4 years' related experience.
- Previous experience in health insurance preferred.
- Excellent customer/interpersonal skills.
- Detail oriented with strong analytical and organizational skills.
- Excellent oral and written communication skills.
- Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database and email applications.
Fresenius Medical Care maintains a drug-free workplace in accordance with applicable federal and state laws.