Provider Enrollment Credentialing Specialist

Primary responsibilities include taking a new provider application from receipt to inclusion on directory along with ongoing updates. This includes accurate and timely entry of provider data including provider applications and contract information, status changes, payee changes, verifying all the credentialing criteria for practitioners that have applied to the network, including both initial and re-credentialing and follow up with practitioners as needed to obtain information for the credentialing process or as a result of mail being returned undeliverable to DentaQuest. 

JOB DUTIES AND RESPONSIBILITIES:

• Enter and maintain Provider applications, contracts and updates into the system.
• Enter and maintain all Provider information into credentialing database.
• Verify potential and existing Provider’s licensure, liability insurance, BNDD, CDS and DEA certificate.
• Verify Provider’s education, hospital privileges, Board certification and other criteria as required.
• Verify accurate banking & billing information.
• Perform ongoing research tocorrect data so it does not create duplicate provider, locations, payees, and participations.
• Maintain credentialing information by reviewing, entering and following up on missing information.
• Review National Practitioners Data Bank for adverse charges pending or filed against Provider.
• Track contract applications status.
• Assure all files have a Welcome, Denial or Term Letter as appropriate.
• Meet required turnaround times and accuracy rates.
• Maintain fee schedules by creating, reviewing and auditing provider fees.
• Keep up to date provider enrollment process and records and track provider participation levels.
• Facilitate provider related research based on suspended claims, PO returns and other feedback opportunities.
• Participation in credentialing committee as necessary.
• Update the system and the credentialing database to reflect approvals, denials and/ or terminations.
• Assist with other duties as assigned.

Skills & Requirements

JOB REQUIREMENTS:

• High School diploma or equivalent, Associate’s degree preferred.
• 1-2 years of experience in business environment.
• Previous experience working with files or the collection and coordination of data preferred.
• Proficient in the use Excel required.
• Experience with general computer software (Word, Outlook required).
• Ability to learn new software programs quickly.
• Good basic math skills.
• Excellent customer service skills.
• Excellent verbal and written communication skills.
• Professional and effective interaction skills with co-workers, clients, Providers, vendors.
• Proven ability to work well individually and as a team member.
• Ability to prioritize and organize multiple tasks.
• Ability to remain organized with multiple interruptions.
• Ability to make independent decisions.
• Strong attention to detail.
• Strong business acumen.
• Ability to adapt to constantly changing environment.
• Ability to work in excess of 40 hours.