Credentialing Specialist

Processes credentialing and re-credentialing applications for the client. Reviews applications and prepares verification letters. Contacts various departments, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications. Provides support to the client in the collection and query of credentials of members of the client.

• Conducts Primary Source Verification (PSV) of credentials such as licenses, certifications, registrations, professional school education, postgraduate, residency, or specialty training, board certifications, work history, and current references.
• Conducts queries through the National Practitioner Data Bank (NPDB), the Defense Practitioner Data Bank (DPDB), the Department of Health and Human Services (DHHS) and TRICARE sanction data banks.
• Collects professional/peer references and completed clinical privileges, demographics, military and civilian practice history (including adverse privileging actions and malpractice history), health status, documentation of contingency and continuing education training, national provider identification number, and for non-personal services contract providers malpractice insurance information.
• Accurately loads appropriate data in the DoD Centralized Credentials Quality Assurance System (CCQAS). Keeps records and documentation of the applications and verifications maintained.
• Establishes and maintains updated CCQAS records.
• Researches and solves credentialing/re-credentialing problems; escalates more complex issues as appropriate.
• Tracks status of credentials for healthcare practitioners and provides required documents to clients to make accession, credentialing and privileging (C&P) decisions.
• Maintains relationships with Military Treatment Facilities and supported customers.
• Ensures providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities.
• Reviews records for regulatory compliance and quality assurance at a healthcare facility, insurance group, or similar organization, ensuring relevant regulations are met.

Minimum Qualifications

• HS diploma or GED; Bachelor’s Degree in healthcare or business field preferred
• Certified Provider Credentialing Specialist (CPCS) preferred
• 2-5 years of experience performing physician credentialing at a medical group, hospital or health plan.

Other Job Specific Skills

• Strong customer focus, interpersonal, collaboration, written/verbal communication, prioritization and computer skills.
• Strong attention to detail and good organizational capability.
• Able to handle multiple simultaneous tasks and complete work projects in designed time frames.
• Knowledge of Department of Defense credentialing guidelines preferred.
• Experience using Centralized Credentials Quality Assurance System (CCQAS) and Defense Medical Human Resources System - internet (DMHRSi) a plus.
• Ability to handle confidential information on a daily basis in a professional manner.
• Ability to consistently maintain quality and production expectations.
• Possess proof-reading skills sufficient for auditing documents.
• Demonstrate familiarity with credentialing policies, guidelines, and regulations for the DoD credentialing process.

Compensation Ranges

Compensation ranges for ASM Research positions vary depending on multiple factors; including but not limited to, location, skill set, level of education, certifications, client requirements, contract-specific affordability, government clearance and investigation level, and years of experience. The compensation displayed for this role is a general guideline based on these factors and is unique to each role. Monetary compensation is one component of ASM's overall compensation and benefits package for employees.

EEO Requirements

It is the policy of ASM that an individual's race, color, religion, sex, disability, age, sexual orientation or national origin are not and will not be considered in any personnel or management decisions. We affirm our commitment to these fundamental policies.

All recruiting, hiring, training, and promoting for all job classifications is done without regard to race, color, religion, sex, disability, or age. All decisions on employment are made to abide by the principle of equal employment.

Physical Requirements

The physical requirements described in "Knowledge, Skills and Abilities" above are representative of those which must be met by an employee to successfully perform the primary functions of this job. (For example, "light office duties' or "lifting up to 50 pounds" or "some travel" required.) Reasonable accommodations may be made to enable individuals with qualifying disabilities, who are otherwise qualified, to perform the primary functions.

Disclaimer

The preceding job description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Originally posted on Himalayas