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Role Description

The Credentialing Specialist for Facilities ensures that the health plan’s provider network includes facilities that meet regulatory standards. This position plays a crucial role in ensuring compliance, safeguarding member safety, and minimizing liability for the company.

Essential Duties & Responsibilities

• Credentialing Review & Evaluation:
  • Evaluate facility credentialing applications for accuracy and completeness based on specialty requirements.
  • Obtain the necessary verifications and ensure compliance with regulatory standards.
• Communication:
  • Engage with facilities to clarify credentialing-related questions and obtain missing information to complete their application.
• Data Entry & Management:
  • Update and maintain credentialing software systems with necessary facility information.
  • Perform data corrections and ensure all files are complete and up to date.
• Recredentialing & Follow-Up:
  • Request and follow up on recredentialing applications, ensuring timely processing and compliance with internal guidelines.
• Monitoring & Compliance:
  • Regularly monitor facilities' expiration dates for licenses, DEA certificates, and other relevant documentation.
  • Present summary reports to the Credentialing Committee monthly.
• Sanctions & Exclusions Review:
  • Review federal and state sanctions/exclusions reports to ensure facilities comply with regulations.
• Reporting & Documentation:
  • Generate and distribute credentialing reports to internal teams.
  • Prepare and send formal notices of approval, requests for additional information, and termination notices as required by the Credentialing Committee.
• Support & Collaboration:
  • Assist the contracting department with credentialing support and provide ongoing status updates on facilities' credentialing status.

Qualifications

• Education: High school diploma required; additional certification or experience in healthcare credentialing is a plus.
• Experience: Prior experience in credentialing or related field preferred, but not required.
• Skills:
  • Proficient in Microsoft Excel and Word; familiarity with credentialing databases is a plus.
  • Strong attention to detail and ability to maintain confidentiality.
  • Flexible, team-oriented, and capable of working with minimal supervision.
  • Strong verbal and written communication skills.