Credentialing Specialist I at Three Point Solutions Inc

Job Title: Credentialing Provider Specialist I
Client: Health Care Insurance Company
Duration: 06 Months
Location: Baltimore, MD 21224

General Information

Job Description:
Purpose:

• Credential practitioners for network participation with Client
• Accurately maintain all provider data within the enterprise-wide Provider file.
• Ensure compliance with regulatory, accreditation, legal, and company requirements and standards.

Essential functions:

• 40%: Analyze credentialing applications to perform primary source verification for Client network participation.
  • Determine the appropriate networks for participation and obtain executed contracts.
  • Reconcile delegated rosters and create provider profile configurations for system loading.
• 30%: Respond to external/internal inquiries regarding provider participation eligibility, credentialing status, and file updates.
  • Provide timely resolution and follow-up, ensuring successful credentialing.
  • Maintain professional etiquette, communication, and decision-making.
• 15%: Maintain provider files, databases, and electronic records during credentialing, recredentialing, demographic updates, and terminations.
• 10%: Identify, analyze, and resolve provider file issues.
  • Ensure compliance with state laws and departmental guidelines.
  • Verify provider data and ensure successful system integration.
• 5%: Prepare written responses for incomplete/missing information and communicate effectively via phone.

Qualifications:
To perform this job successfully, an individual must meet the following criteria:

Education Level:

• High School Diploma required.

Experience:

• 3 years of physician credentialing experience or health insurance/managed care operations in customer service, claims, billing, enrollment, or call center environments.

Preferred Qualifications:

• Bachelor's Degree in Business, Healthcare Administration, or related field.

Knowledge, Skills, and Abilities (KSAs)

• Proficient in Excel spreadsheets and Pivot tables.
• Excellent verbal and written communication and interpersonal skills.
• Ability to develop and maintain effective relationships with peers, physicians, and medical staff.
• Knowledge of medical terminology.
• Proficiency in utilizing reference materials and following Standard Operating Procedures to ensure provider data accuracy.
• Understanding of jurisdictional requirements and the legal ramifications of credentialing and provider file maintenance.

Additional Requirements:

• Must disclose any debarment, exclusion, or other events making the individual ineligible to perform work on Federal healthcare programs.
• Must effectively work in a fast-paced environment with changing priorities, deadlines, and workloads.
• Must handle multiple customer service demands while maintaining high service standards.
• Must provide positive customer service to internal and external customers, including those who are demanding or challenging.

Licenses/Certifications:

• Certified Provider Credentialing Specialist (CPCS) preferred.

Additional Skills:

• Strong communication skills, both written and verbal.
• Proficiency in Microsoft Excel.

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