Job Description

Job Description: Health Insurance Credentialist Position Summary: We are seeking a skilled and detail-oriented Health Insurance Credentialist to join our team. As a Health Insurance Credentialist, you will be responsible for ensuring that healthcare providers within our organization maintain the necessary credentials and licenses required for rendering services to patients. You will work closely with the provider relations department and other cross-functional teams to ensure compliance with all regulatory standards and policies. Responsibilities:

1. Credentialing Process: Perform the credentialing process for new and existing healthcare providers, including but not limited to physicians, nurses, therapists, and other allied health professionals.
2. Verification: Ensure the accuracy and completeness of all provider information by conducting thorough verification of credentials, licenses, certifications, education, training, and work history.
3. Documentation: Maintain and update comprehensive provider profiles containing accurate and up-to-date demographic information, board certifications, professional references, malpractice claims history, and any other supporting documentation as per regulatory requirements.
4. Compliance: Ensure adherence to all federal, state, and local laws, regulations, and guidelines related to healthcare provider credentialing, privileging, and enrollment in various health insurance plans.
5. Network Participation: Collaborate with provider relations team to support the enrollment, re-credentialing, and network participation process to ensure timely and accurate completion.
6. Internal Coordination: Work closely with internal stakeholders, such as human resources, legal, billing, and finance departments, to maintain accurate and consistent provider information across systems.
7. Monitoring and Auditing: Conduct periodic audits to monitor and evaluate compliance with credentialing policies and procedures, identifying any areas of concern and recommending appropriate corrective actions.
8. Communication: Facilitate effective communication with healthcare providers, insurance companies, and regulatory agencies to obtain and exchange necessary information related to credentialing activities.
9. Continuous Improvement: Review and enhance credentialing processes, policies, and workflow to promote efficiency and ensure compliance with changing industry standards.
10. Training and Education: Provide training and education to providers and staff on credentialing requirements, processes, and documentation to ensure awareness and adherence to established protocols.

Qualifications:

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional in Medical Services Management (CPMSM) certification desired.
• Previous experience in healthcare provider credentialing, privileging, or enrollment, preferably in an insurance or managed care setting.
• Strong knowledge of federal and state regulatory requirements related to credentialing and privileging.
• Familiarity with CAQH, NCQA, and Joint Commission standards and processes.
• Proficiency in using credentialing software and databases.
• Excellent attention to detail, organizational skills, and ability to prioritize tasks effectively.
• Strong analytical, problem-solving, and decision-making abilities.
• Effective written and verbal communication skills.
• Ability to maintain confidentiality of sensitive information.
• Strong interpersonal skills and ability to work collaboratively with cross-functional teams.

This job description outlines the primary duties and qualifications expected of a Health Insurance Credentialist. However, additional responsibilities may be assigned based on the evolving needs of the organization. We offer 100% paid medical, 401k, generous time off allowances, and paid vacations. This is a fully remote position for the correct candidate.

Job Tags

Local area, Remote job,

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