Credentialing Specialist II

 In

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Reference Code: 4810

Position Title: Credentialing Specialist II
Location: 100% remote position, Irving, TX, 75038
Duration: 6 months contract with possible extension
Target start date: 3/12/2021

• 100% Remote position.
• Candidates may be located anywhere in the US, HOWEVER must have knowledge of TX credentialing requirements
• REQUIRED: TX credentialing standards including NCQA
• Day-to-Day Responsibilities: Prepare files for credentialing committee, coordinate with network team to review and approve cred documentation, ongoing monitoring of providers in network for items such as sanctions and license revocations, oversight of recredentialing process and termination of providers who fall out of compliance, review and approve providers for expedited credentialing in alignment with Texas Insurance/Administration codes, and align with provider data load team to ensure congruence in the contract to in network process.
• Shift: M-F 8am-5pm

SUMMARY:
Responsible for coordinating all aspects of the credentialing and primary source verification process for practitioners and health delivery organizations according to  policy and procedures.

ESSENTIAL FUNCTIONS:
Processing Specialist
• Process initial and recredentialing applications from providers, meeting departmental requirements.
• Complete data entry of applications, reviewing them for errors prior to turning in the provider files for quality review, meeting departmental requirements.
• Process the minimum number of provider applications each month, meeting departmental requirements.

Recredentialing/Termination Specialist
• Prepare and send out recredentialing groups, meeting departmental requirements.
• Complete 1st, 2nd and 3rd requests for recredentialing packets, meeting departmental requirements.
• Send report to various state plans/departments to identify any providers who haven’t returned their recredentialing applications or who are past-due for credentialing, meeting departmental requirements.

Ongoing Monitoring/Watch Follow-up Specialist
• Complete follow-up for provider files on ?watch? status, meeting departmental requirements.
• Ensure that follow-up occurs for the ongoing state license action monitoring reports, meeting departmental requirements.
• Ensure that follow-up occurs for the ongoing Medicare/Medicaid sanctions monitoring reports, meeting departmental requirements.

Delegation Specialist
• Maintain the minimum volume of delegated provider entered into CACTUS to ensure expected levels of productivity, meeting departmental requirements.
• Enter data into CACTUS of delegate information should be done within required timeframes, meeting departmental requirements.
• Update delegate information received from delegate groups should be completed within required timeframes, meeting departmental requirements.

KNOWLEDGE/SKILLS/ABILITIES:
• Ability to multi-task efficiently. Superb written and verbal communication skills. Competence with computers and data entry.
• Knowledge of NCQA, CMS, and credentialing criteria. Ability to professionally adapt to a rapidly changing environment and rule set.
• Excellent verbal and written communication skills
• Ability to abide by policies
• Ability to maintain attendance to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

REQUIRED EDUCATION:
High School Diploma or equivalent

REQUIRED EXPERIENCE:
2-4 years of relevant experience

REQUIRED LICENSURE/CERTIFICATION:
Certified Provider Credentialing Specialist (CPCS) or, participation in a CPCS progression program.

 

 

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