Credentialing Specialist

Description:

Scope of Role & Responsibilities

• Maintain communication with the credentialing contacts at facilities and provider sites to coordinate receipt

of information required for credentialing, re-credentialing, and update of provider credentialing information

• Review provider re-credentialing and credentialing file for completion and presentation to the Credentialing

Committee.

• Perform primary source verification on required elements and in accordance regulatory guidelines and

policies and procedures

• Data entry and upkeep of provider information in the credentialing and other pertinent databases

• Verify New York State OPMC, Medicare/Medicaid lists and other pertinent databases for any current

sanctions, restrictions on licensure and/or limitations on the scope of practice on all credentialed providers

in interim credentialing periods

• Verify New York State license registration and DEA registration status for all credentialed providers in the

interim credentialing periods

• Generate and disseminate monthly provider credentialing updates to appropriate departments and participating facilities and provider groups

• Review and respond to request for credentialing information/copies of credentialing files to appropriate

departments

• Generate and disseminate provider rosters to delegated facilities, contracted group practices etc.

• Perform provider roster reconciliation

• Create, copy, file, and maintain all relevant documentation into provider credentialing folder.

• Maintain confidentiality of provider credentials by filing the credentialing folder in respective cabinets in

the file rooms.

• Perform annual delegated file audits and participate in pre-delegation and delegation site reviews

• Respond to inquiries from other departments relative to a provider’s credentialing status

• Performs other related tasks as directed by the Deputy Chief Operating Officer or her designee, the

Credentialing Director or Credentialing Team Lead.

Required Education, Training & Professional Experience

• High school Degree required; Bachelor’s Degree preferred

• 2 years of previous experience with provider credentialing processes and procedures

• Knowledge of CACTUS or MD-Staff preferred

• Must be able to handle multiple projects simultaneously.

• Comprehensive knowledge of managed care with a specific emphasis on physician credentialing.

• Ability to meet time-sensitive deadlines and multi-task in a changing healthcare environment.

• Understanding of credentialing activities as they relate to initial credentialing, re-credentialing, and

credentials modification(s).

Requirements: