[Hiring] Credentialing and Contracting Medical Provider Network Specialist @Tristar Insurance

Role Description The Credentialing and Contracting Specialist is responsible for preparing and maintaining contracts and the contracts database system. Maintain active status for all providers by successfully completing initial and subsequent credentialing packages as required by state regulations, guidelines and policies. Essential Duties and Responsibilities

• Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with regulations, guidelines, policies, and standards. Monitors Applications and follows-up as needed.
• Conducts primary source verification, collects and validates documents (state license, DEA Certificates, malpractice coverage, etc.) to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards to ensure timely renewal. Maintains provider contract files.
• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to Director for sound decision making in accordance with credentialing policies and procedures, state regulations.
• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
• Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
• Participates in the development and implementation of process improvements for the credentialing process.
• Communicates clearly with providers, their liaisons, and staff as needed to provide timely responses upon request on day-to-day credentialing, provider, staff and client issues as they arise.
• Assists in helping find available physician(s) when unavailable within the Network.
• Maintains professional growth and development through professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
• Performs miscellaneous job-related duties as assigned.

Qualifications

• Ability to communicate effectively both orally and in writing.
• Customer service skills.
• Ability to respond to emails timely and effectively.
• Information research skills.
• Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications.
• Ability to make administrative/procedural decisions and judgments.
• Demonstrated advanced working knowledge of Microsoft Word and Excel.
• Ability to learn new applications to function effectively in a remote work environment.
• Skill in establishing priorities with independent coordination of day-to-day aspects.
• Skills in computerized spreadsheeting and database management.
• Ability to organize and prioritize work and manage multiple priorities.

Requirements

• High school diploma or equivalent required.
• Computer skills required with knowledge in utilizing Outlook, Microsoft Word, Excel and other databases.

Benefits

• Medical, Dental, Vision Insurance
• Life & Disability Insurance
• Paid time off
• Paid holidays
• 401(k) plan
• Referral bonus