Credentialing Specialist I at Three Point Solutions Inc
Baltimore, MD
About the Job
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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