Company: District Medical Group
Posted on: November 23, 2021
About the Role:The HP Credentialing Specialist, under general
supervision, work with physicians and allied health providers to
facilitate the health plan credentialing / enrollment process to
ensure that complete and accurate information is forwarded to
health plans in a timely manner. As required by Credentialing
Department policy, initiate follow-up with providers and health
plans to ensure the process is continuing without unnecessary
delays. Follow process to completion resulting in provider becoming
contracted and receiving a specific provider identification number
from each health plan in order for the billing process to
commence.What You Will Do:
- Process health plan enrollment / credentialing applications for
physicians and allied health providers.
- Review and analyze provider's returned paperwork to ensure
completeness of information.
- Identify and flag adverse information received from materials
completed by the provider for the purpose of conducting special
investigation; reporting this information to the Credentialing
Specialist for follow-up.
- Maintain tickler system outside of the credentialing database
for follow-up of outstanding paperwork and unanswered
correspondence according to schedules designed to maintain
department standards for application processing time.
- Run weekly reports from the credentialing database to determine
required follow-up with providers and health plans.
- Enter contact and action notes into credentialing database to
maintain accurate record of progress with health plans.
- Maintain credentialing database and billing database updating
provider health plan identification numbers and other required
- Organize and maintain provider health plan files and
information following confidentiality guidelines.
- Share updated information (i.e., address changes, updated
licensing or certification documentation) received from the
provider during the enrollment / credentialing process with the
Credentialing Specialist for input into the credentialing
- Employ public relations skills in a wide variety of contacts
with internal and external sources for purposes of soliciting
information essential to health plan enrollment /
- Establish and maintain a professional working relationship with
providers, their outside office staff, internal staff, and health
- Proficient in the use of Visual Cactus (credentialing database)
to enhance the health plan credentialing process and become
proficient with its reporting functions.
- Proficient in the use of Microsoft Word and Excel for Visual
Cactus; NPI (National Practitioner Identification on-line access);
Certifacts (American Board of Medical Specialties on-line access);
State licensing agencies on-line access and Internet Explorer for
other internet access.
- Perform varied clerical / secretarial support functions
- Perform related duties as assigned by supervisor.
- Maintain compliance with all company policies and
procedures.What You Will Bring to the Role:Experience:
- One year of credentialing or medical administrative experience
in a hospital, managed care, or physician office practice setting
- High school diploma or equivalent
- Certification by the National Association of Medical Staff
Services in Certified Professional Medical Services Management
(CPMSM) or Certified Professional Credentialing Specialist (CPCS)
- Understanding of the basic process for enrolling /
credentialing providers with health plans.
- Understanding of each health plan's requirements for completion
of all necessary paperwork needed for credentialing / enrollment
- Understanding of the need of the credentialing process in the
health care environment and the impact on quality patient
- Basic knowledge of claims billing and/or contracting
- Familiarity with the National Association for Quality Assurance
Standards and Guidelines for MCO accreditation.
- Problem solving and decision making
- Understanding/compliance of HIPAA laws and regulations
- Computer proficiency (MS Office - Word, Excel and Outlook)
- Highly organized with excellent attention to detail and a
demonstrated high regard for clerical accuracy
- Excellent verbal and handwriting skills
- Ability to read, extract and interpret information comparing
such to established departmental policies
- Excellent customer services and public relations skills
- Must be flexible and willing to work extra hours during peak
workloads and deadlines
- Ability to work as a team player with willingness to assist
other team members as needed.
- Must be able to work under pressure and meet deadlines
- Self-motivated with the ability to work independently and to
carry out assignments to completion within parameters of
instructions given, established timeframes, prescribed routines,
and standard accepted practices.
- Ability to operate standard office machines and equipment,
including telephones, computers, copy machines, fax machines,
calculators, scanners and shredders.
- Ability to safely and successfully perform the essential job
functions consistent with the ADA, FMLA and other federal, state
and local standards, including meeting qualitative and/or
quantitative productivity standards.
- Ability to maintain regular, punctual attendance consistent
with the ADA, FMLA and other federal, state and local
- Ability to type __35__wpm
- Experience in processing out of state Medicaid and behavioral
health plan provider enrollment preferred.Physical Requirements:
- Must be able to lift and carry up to 20 lbs
- Must be able to talk, listen and speak clearly on
- Requires sitting and standing associated with a normal office
- Manual dexterity needed for using a computer keyboard.
- Specific vision abilities include close vision, distance
vision, depth perception and the ability to adjust
focus.Environmental Working Conditions:
- Normal office environment.
- The noise level of the work environment is usually low to
- Occasional overtime maybe required and/or hours may be
shortened as business needs dictate.
Keywords: District Medical Group, Phoenix , Credentialing Specialist, Other , Phoenix, Arizona
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