Overview
We are seeking a highly motivated and detail-oriented Credentialing Specialist/Director to lead our credentialing operations within the healthcare sector. This pivotal role involves managing the comprehensive credentialing and provider enrollment processes to ensure compliance with all relevant healthcare regulations and accreditation standards. The successful candidate will oversee the verification, review, and maintenance of provider credentials, ensuring seamless integration with healthcare payers, regulatory bodies, and internal policies. Join us to play a vital role in maintaining the integrity and compliance of our healthcare organization while fostering a culture of excellence and precision.
Responsibilities
• Lead and coordinate the medical credentialing process, including application review, verification of licensure, certifications, and other credentials in accordance with NCQA standards and regulatory requirements.
• Manage medical payer enrollment activities, ensuring timely submission of credentialing applications to Medicare, Medicaid, private insurers, and other health plans in compliance with CMS regulations.
• Oversee the use of healthcare software applications and medical credentialing software to maintain accurate provider databases and credentialing records.
• Review medical credentialing applications thoroughly for accuracy, completeness, and compliance with state healthcare regulations and JCAHO accreditation standards.
• Maintain up-to-date knowledge of health regulation policies, CMS guidelines, and healthcare compliance requirements to ensure organizational adherence.
• Develop and implement policies for handling confidential information securely while managing sensitive provider data in accordance with HIPAA regulations.
• Collaborate with contract management teams to ensure provider agreements meet regulatory standards and organizational needs.
Requirements
• Proven experience in managed care environments with a strong understanding of health insurance processes, payer enrollment procedures, and healthcare software applications.
• Extensive administrative experience within healthcare settings, including medical office operations or medical credentialing departments.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook) along with experience using medical credentialing software and healthcare databases for efficient data management.
• Knowledge of medical terminology, health regulation policies (including CMS regulations), NCQA standards, JCAHO accreditation standards, and state healthcare regulations.
• Demonstrated ability to review medical credentialing applications accurately while ensuring regulatory compliance across multiple payers and agencies.
• Strong contract management skills within a healthcare context coupled with experience navigating CMS regulatory compliance requirements.
• Excellent organizational skills with a keen eye for detail; ability to handle confidential information discreetly while managing multiple priorities effectively.
Join us to be part of a dynamic team dedicated to excellence in healthcare credentialing! We value proactive professionals who thrive in fast-paced environments and are committed to maintaining the highest standards of compliance and quality assurance across all operational facets.
Pay: $25.63 - $30.87 per hour
Work Location: Remote