Credentialing Specialist Resume Samples

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C Hansen

Cora

Hansen

2691 Stamm Motorway

Chicago

+1 (555) 404 3351

2691 Stamm Motorway

Chicago

Phone

p +1 (555) 404 3351

Experience Experience

Boston, MA

Credentialing Specialist

Boston, MA

Fay Group

Boston, MA

Credentialing Specialist

Accurately enter information into Network Connect (NWC) for all potential network providers and/or existing providers being re-credentialed for the network
Works with Network Management team, study managers and regulatory personnel to achieve goals for quality assurance and compliance
Works with Network Contracting and Provider Relations departments and other Beacon staff to ensure follow up with providers when applications are incomplete
Works with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete
May assist in provider education and preparation of provider training materials
Act as project leader and assist in the development of provider data reporting, as requested
Perform delegated Credentialing duties as assigned by the Network Manager and according to existing

Boston, MA

Associate Credentialing Specialist

Boston, MA

Yost-Leuschke

Boston, MA

Associate Credentialing Specialist

Assist in goals and performance standards management
Create and maintain provider files in compliance with the organization’s policies
Improve efficiencies and service provided while reducing costs
Assist with various projects as assigned by direct supervisor
Attend trainings and reference materials including content, work instructions, and tools
Abide by all policies, procedures, and work instructions for the credentialing function of the Medicare Advantage plan
Perform quality checks

present

New York, NY

Provider Enrollment Credentialing Specialist

New York, NY

Lind, Gaylord and Fisher

present

New York, NY

Provider Enrollment Credentialing Specialist

present

Perform ongoing research to correct data so it does not create duplicate provider, locations, payees, and participation
Keep up to date provider enrollment process and records and track provider participation levels
Facilitate provider related research based on suspended claims, PO returns and other feedback opportunities
Maintain fee schedules by creating, reviewing and auditing provider fees
Review National Practitioners Data Bank for adverse charges pending or filed against Provider
Assist with other duties as assigned
Enter and maintain Provider applications, contracts and updates into the system

Education Education

Bachelor’s Degree in Business

University of Georgia

Bachelor’s Degree in Business

Skills Skills

Acquires and maintains knowledge of relevant product offerings, current support policies, and methods of support delivery, in order to provide technically accurate solutions to users
Researches, resolves, and responds to end-user/problems/questions received via email, telephone calls, callbacks, web requests or escalations, and provides support on technology platforms, in accordance with current standards and service levels
Coordinates user and support issues among corporate site and remote office locations to ensure timely distribution of knowledge and positive impact on user satisfaction and productivity
Great interpersonal skills
Excellent communication skills (written and verbal)
Strong attention to detail
Highly organized
Able to multitask efficiently and effectively
Ability to prioritize and complete projects within deadlines
Strong organizational, analytical, detailed-oriented, and interpersonal skills

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15 Credentialing Specialist resume templates

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Credentialing Specialist Resume Examples & Samples

Our Department of Defense contract requires U.S. Citizenship
Working knowledge of computers, or a demonstrated technical aptitude and and ability to quickly learn new systems
Associate’s or Bachelor’s Degree in a healthcare field or related field
Two years experience in provider relations, customer service in healthcare field or credentialing

Credentialing Specialist Resume Examples & Samples

Associate's Degree in healthcare administration, business or an equivalent combination of education and related work experience in managed care or healthcare
1+ year of experience in provider credentialing
Strong organizational, analytical, detailed-oriented, and interpersonal skills
Knowledge of provider databases programs

Credentialing Specialist Resume Examples & Samples

Proficiency with Microsoft Office Word and Excel
Must have excellent time management and communication skills
Working knowledge of APEX and/or Singlepoint
Prior experience with credentialing

Credentialing Specialist Resume Examples & Samples

1+ year of Credentialing experience
Proficiency with Credentialing software (Cactus, IntelliSoft, Vistar, Morrisey, etc.)
Knowledge of Hospital functions and Medical terminology
5+ years of Hospital Credentialing experience
College Degree

Credentialing Specialist Resume Examples & Samples

Be responsible for credentialing and re-credentialing of all providers through primary source verifications (e.g. OIG, GSA/SAMS, NPDB, Boards, AMA, National Student Clearinghouse, various licensing agencies MSO and Medical Internship, Residency and Fellowship schools)
Maintain providers file with updated information
Follow up with clinicians/vendors and the staffing department for missing information, monthly tracking of expired licenses; scanning and indexing
Audit and submit files to Credentialing Manager for approval
Respond to all queries/questions from Staffing Department, Credentialing Committee, Director of operations and the different management teams
Completing special projects as assigned
1 year Credentialing Experience
2 years Healthcare Experience
Associate’s or Bachelor’s Degree in Business, Finance or a related field Reporting Relationships

Credentialing Specialist Resume Examples & Samples

Check provider applications on initial/recred credentialing for completeness and accuracy and follow-up, obtaining missing elements as necessary, including PLI exceptions and hospital waivers
Intervene as necessary to resolve issues involving unusual cases and processes, responding to field staff, provider office associates, Network Development, etc…
Supports the Credentialing Committee process
Timely and accurate completes primary source verification (PSV) of credentialing data in the Humana Government Business credentialing system (CVS)
Associates or Bachelor’s degree in health care related or similar field preferred. May substitute equivalent education and/or experience for degree
Proficiency in the MS Office Programs including Word, Excel, and Access or similar PC based applications required
Good written and verbal communication skills required
Our Department of Defense Contract requires U.S. citizenship for this position
Two years’ experience in provider relations, customer service in healthcare, or credentialing preferred
Knowledge of URAC Credentialing standards preferred

Credentialing Specialist Resume Examples & Samples

1-2 years of credentialing experience
Demonstrated proficiency in data entry, Microsoft Word and Excel
Demonstrated proficiency in credentialing software
Knowledge of hospital functions and medical terminology
5 years of hospital credentialing experience

Credentialing Specialist Resume Examples & Samples

2+ years of previous experience in a Health Insurance environment, preferably in provider relations or credentialing
Associate's Degree or an equivalent combination of education and experience
Working knowledge of Amisys Advanced
Solid knowledge of Medical terminology
Experience in Provider Relations or Credentialing
Knowledge of NCQA and CMS requirements

Credentialing Specialist Resume Examples & Samples

1 year of previous medical staff credentialing experience
Demonstrated knowledge of credentialing procedures, policies and terminology
Strong proficiency in Microsoft Office Suite

Credentialing Specialist Resume Examples & Samples

Maintain electronic files that meet all regulatory agencies
Serve as the person responsible for processing credentials files that contain dated accurate approved content on time, verify a professional history, communicate the status directly to providers and administrators and meet regulations
Monitor all aspects of the file process and evaluate for a total picture of the physician’s background

Credentialing Specialist Resume Examples & Samples

1-3 years credentialing or related experience; or any combination of education and experience, which would provide an equivalent background
Excellent computer skills, including word processing, spreadsheet and database management software
Strong oral and written communication and research/problem solving skills
Experience/knowledge with NCQA standards

Credentialing Specialist Resume Examples & Samples

Receives provider applications and contacts providers for any additional supporting documentation or clarification
Builds file documentation and prepares file for credentialing committee review. Applies general guidelines in determining whether provider meets criteria and documents deficiencies
Prepares correspondence to providers regarding status
Assists in researching pended and probated applications and resolving discrepancies
Refers non-approved providers or questionable situations to senior representative
May assist in provider education and preparation of provider training materials

Credentialing Specialist Resume Examples & Samples

Processes initial and reappointment credentialing applications as assigned
Effective data entry of documentation from initial and reappointment applications
Conducts follow up of outstanding information and verifications in a timely and effective manner in alignment with CVO processing guidelines
Conducts audits of initial and reappointment credentials files as assigned
Responsible for meeting set performance goals with regard to quality and accuracy of work
Manages and prioritizes assigned work so that turnaround time goals are met, in process files are kept up-to-date, and assigned files are processed in a timely manner
Performs related and unrelated tasks as assigned
Ability to work collaboratively and train others
Knowledge of hospital credentialing and privileging preferred
Knowledge of CACTUS Credentialing System desired
Healthcare insurance experience preferred
Payer enrollment experience preferred

Credentialing Specialist Resume Examples & Samples

Associate’s degree or equivalent preferred but not required (i.e. some college)
Requires 1-3 years of experience in health care credentialing/ verification
Knowledge of Health Line System (Medical Staff Line and/or Echo) or other credentialing system preferred
Knowledge of basic anatomy and physiology, medical terminology and functions of medical staff services
Advanced computer skills in word processing, spread sheets and databases

Credentialing Specialist Resume Examples & Samples

Recent experience is deemed to be within the last five (5) years
Medical Staff Services Office provides credentialing to medical practitioners to ensure they meet the standard requirements that are necessary for them to perform their medical duties
*Experience at the level of Intermediate Typist Clerk in the County of Los Angeles is defined as: Positions allocable to this class, in addition to performing skilled typing work, perform specialized clerical duties requiring a working knowledge of specialized subject matter and the specialized clerical functions involved and the use of initiative and judgment with procedural and policy limits

Credentialing Specialist Resume Examples & Samples

A minimum of three years' experience in a medical staff office or healthcare administration required
Knowledge of applicable JCAHO and NCQA standards as well as Federal and State regulations
Two (2) + years of college preferred
Five (5) + years working with a variety of healthcare providers preferred
Excellent oral and written communication skills; attention to detail;strong planning and organizational skills; ability to evaluate and prioritize; ability to meet critical time deadlines; ability to work under stress; ability to initiate and follow-through independently; decision-making, problem-solving and judgment skills; computer database skills and software application programs (Microsoft Office); ability to utilize and understand medical terminology
Must maintain confidentiality of information

Senior Non-delegated Credentialing Specialist Resume Examples & Samples

Coordinate and expedite document flow in the development and completion of applications in a timely manner to include interfacing with payer; the applicant; to ensure timely compliance with all applicable standards including but not limited to NCQA and URAC
Serve and primary trainer for customer practices concerning the submission and maintenance of credentialing data
Submit reports to management concerning the status of assigned applications
Assume the duties of Non-Delegated Credentialing Manager in their absence
Mastery of the credentialing application process with commercial carriers and government programs
Five (5) years’ experience in health care with a payer, physician practice, and/or working in a facility in the hospital privileges or managed care function
Demonstrated experience in customer service and handling highly sensitive medical information

Credentialing Specialist Resume Examples & Samples

Processes both initial and re-credentialing applications in accordance with bylaws, policies and procedures for presentation to Credentialing Committee
Provides information to other MHS staff members allowing maintenance of both payer files and directories
Serves as “back-up” for MHS staff involved in claims resolution for providers and payer relations

Credentialing Specialist Resume Examples & Samples

Minimum experience of six (6) years as executive/legal and three (3) years in a Medical Staff Office in a hospital setting
Able to take minutes
Demonstrates computer literacy knowledge of Word, Excel, Access, etc
High energy necessary, must be able to handle multi-tasks
Must be able and have transportation between facilities
(CPCS) Certification Provider Credentialing Specialist Certification desired

Credentialing Specialist Resume Examples & Samples

Manage the process of sending initial and/or reappointment applications and monitoring their return with required documents
Responsible for processing appointment/reappointment applications in an accurate, thorough, and timely manner; clearly and succinctly communicate reappointment status to applicant in writing
File appointment/reappointment applications and other communication as needed
Prepare files other documents, as requested, for review and evaluation of the clinical Service Chief and Credentials Committee in an accurate, consistent, professional, and organized manner
Perform 3rd party verifications of submitted material as required by department policy, medical staff policy, and the Bylaws of the Medical Staff
Document receipt of application materials and verifications in the credentialing system (ECHO) (e.g. Texas Medical License, Malpractice Insurance, DEA, Board Certification, DPS, etc.). File copy in physician's file
Ensure all credentialing-related information is accurate and up to date in the ECHO system and in the applicant files
With the assistance of the Supervisor, utilize Echo to run reports and make certain all certifications and other tracked information as required is up to date and accurate
Proficiency in Word and Excel
Excellent data entry skills
Knowledge and usage of office equipment (i.e. printer, copier, fax machine, scanner)
Previous Medical Staff Credentialing experience

Client Credentialing Specialist Resume Examples & Samples

Works under limited supervision and is competent to perform most aspects of the job independently
Follows guidelines and procedures
Errors may result in the company being out of compliance with credit repositories and/or regulatory entities
Proficient in Microsoft Office Products, Word, Excel and Outlook
HS Diploma/GED required; some college preferred
Intermediate knowledge of Microsoft Office products is preferred
Entry Level Position. On the job training provided

Credentialing Specialist Resume Examples & Samples

1-2 years working experience in a healthcare administrative support position
Credentialing certification from a nationally recognized organization is preferred
Must meet satisfactory completion of all training and testing: Data Entry 9000 KPH, Correspondence test, CRM Navigation
Ability to multitask in fast paced environment
Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills
Proficiency in English language skills including spelling punctuation and grammar in both written and verbal communication to ensure communications are issued in a professional manner
Ability to effectively communicate in both written and verbal communication with internal and external contacts in a professional manner
Working knowledge of personal computer and application software such as Microsoft Office
Computer Software typically used: Microsoft Office, Facets, Internet

Credentialing Specialist Resume Examples & Samples

Must be able to work in a team oriented environment
Working knowledge of Microsoft Word and Excel
CAQH experience preferred but not required

Credentialing Specialist Resume Examples & Samples

Obtains, verifies and maintains necessary practitioner credentialing/re-credentialing, demographic, and industry and regulatory body driven information
Performs credentialing/recredentialng activities and data entry into the credentialing database to meet established deadlines and ensure quality of data and integrity of information for presentation to the Credentialing Committee, submission on monthly rosters and reports
Follows the messenger model process, as needed, for independent community practitioners
Credentials and recredentials practitioners and providers directly contracted for the Cleveland Clinic Employee Health Plan
Develops, prepares and distributes standard and ad hoc reports in accordance with established schedules and requests
Completes credentialing and recredentialing applications for contracted health plans for all CCHS owned facilities to maintain revenue stream
Completes health plan enrollment activities for non-delegated plans
Applies for and maintains clinical privileges for CC practitioners at Nevada hospitals
Updates Council for Affordable Quality Health Care (CAQH) applications as needed
Completes Medicare, Medicaid and BWC validations and revalidations as needed
Completes health plan directory audits to comply with CCF initiatives, CMS and NCQA requirements as needed
Researches and resolves practitioner loading and claims issues for employed and independent practitioners with contracted health plans
Performs administrative tasks to support the initiatives of the Quality Alliance to include, entry and updating of new and existing Quality Alliance practitioners into Salesforce, reconciliation and auditing of reports and rosters to ensure networks are accurate and complete, collection of data regarding practice management systems, electronic funds transfer, and follow up with health plans regarding incentive payments and other provider inquiries
Collects and maintains agreements for Quality Alliance providers, including Quality Alliance participation and ACO (Accountable Care Organization) agreements
Reconciles verbiage in agreements with CMS data and requests new agreements as needed to comply with CMS reporting requirements
Assists in preparation of ACO submission lists
Minimum of three years of experience in hospital, managed care organization, health plan, network management or provider relations working with multi-specialty groups or other integrated delivery systems

Temporary Dental Credentialing Specialist Resume Examples & Samples

The position will collect and maintain up-to-date files in relation to credentialing including applications, contracts, licenses, DEA licenses, NPI numbers and other pertinent information
Prepares, submits and tracks insurance credentialing applications. Prioritizes and resolves inquiries on a timely basis
Reviews practitioners’ credentials to ensure that they are up-to-date. Accurate completion of forms, obtaining the practitioner’s signature, making file copies, and sending documentation to the appropriate facilities
This position should have the ability to search and maintain (as applicable) external websites for credentialing related information including, but not limited to, CAQH, PECOS, and NC Tracks
Position will communicate with providers and Patient Business Services staff members when necessary in a professional and courteous manner. Obtains verifications, performs data entry, accurately proofreads own work, maintains confidentiality, analyze data and make recommendation to supervisor, performs research and gathers data from multiple sources
Maintains the credentialing database. Scans credentialing verification information into appropriate practitioner folders
Monitors changing insurance credentialing rules/regulations. Ensures that all practitioners are in compliance with same
Completes all other duties as assigned
Associate’s degree is required. A combination of education and experience will be considered
Have clear and concise phone and verbal communication skills. Ability to write legibly
Demonstrate effective written communication skills
Have strong computer, typing, and data entry skills: includes MS Word, Excel and web-based applications, internet, and database programs
Detail oriented with ability to recognize vital information from verification documents
Possess proof-reading skills sufficient for auditing documents
Ability to prioritize well and meet overlapping deadlines
Demonstrate problem-solving, critical thinking, and deductive reasoning skills
Ability to consistently maintain quality and production expectations

Credentialing Specialist Resume Examples & Samples

Support assessment and evaluations of CDO credentialing capabilities to ensure national standards and guidelines are met for delegated credentialing
Work in conjunction with Credentialing and Contracting Implementation team to ensure workflows implemented support utilization of eVIPs
Conducts audits of eVIPs, confirming accurate input of provider data, including auditing other staff data entry and verifying accuracy of modifications made to the database. Monitor security of data within the eVIPs with individuals to whom data or system access may be given; report infractions to the Associate Director
Maintain current knowledge of computer hardware and database software capabilities
Orient new staff to appropriate database use, capabilities, security, etc
Act as project leader and assists in the development of provider data reporting, as requested. Collaborate with Information Technology to review approved software installs, upgrades, incremental backups and restorations; assist in the development of configuration documentation and updates as necessary
Work with local teams to maintain appropriate logs of database-related problems and modifications; monitor database performance and space; investigate and resolve all departmental problems, questions and concerns, and make modifications, as necessary
Disseminate new / modified professional information to HMOs and to CDOs through the Information System Change Control Process
Implement processes around credentialing/re-credentialing applications accurately and promptly in accordance with internal medical group policies and procedures and NCQA standards. Provide guidance on the coordination of the credentialing and re-credentialing processes with the Quality Improvement Department and other internal departments, as necessary
Accepts and performs other duties and responsibility as assigned
4 year college degree, health care related field preferred or equivalent work experience
2+ years of experience in credentialing, preferably in a managed care setting
Must be eligible to take the National Association Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist exam within the first 18 months of employment
Must be a team player with excellent communication skills, both written and verbal
Strong organization and administrative skills, attention to detail and the ability to follow through
Must be able to prioritize many tasks and exhibit excellent, mature judgment
Excellent writing skills and attention to detail
Complies with company and departmental administrative policies and procedures; performs job safely with respect to others and to property
Maintains strict confidence of client information, ensuring client's privacy; and does not discuss internal business with external entities
Knowledge of Practice Management Software and Intellisoft Software System

Credentialing Specialist Lead Resume Examples & Samples

Requires a BA/BS degree in a related field
5-7 years credentialing experience; or any combination of education and experience, which would provide an equivalent background
Certification preferred
NCQA knowledge required
Experience leading credentialing initiatives and projects
NCQA audit experience preferred

Corp Credentialing Specialist Resume Examples & Samples

Education: High school graduate, Associates Degree preferred
Experience: 6 months experience with a high school diploma in a credentialing or medical staff office setting, and privilege research or 0 months experience with an Associate's Degree in a Healthcare related field Licensure: CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Staff Management) Certification through NAMSS preferred
Skills & Abilities: Excellent interpersonal, communication and administrative skills; possess self-motivation, analytical and organizational skills; including basic record keeping, typing, computer website usage, filing practices, written/oral communication skills, ability to initiate inquires and follow-up with minimal supervision; work in a stress-filled, fast-paced environment to meet stringent timelines and ongoing deadlines; strong knowledge of Word, Excel, Access and credentialing database systems as well as JCAHO, NCQA, Federal and State standards and regulations regarding medical staff services

Credentialing Specialist Resume Examples & Samples

Differentiates manner of care, communication, and service to maximize effectiveness with age specific population
Ensures that all credentialing and re-credentialing of Medical Staff and Allied Health Professionals (AHP) applications are processed in compliance with Medical Staff Bylaws and Rules and Regulations
Processes credentialing files of Physicians/AHP's consisting of verifying education and training, licenses, board certification or eligibility, National Practitioner Data Bank, peer references, malpractice insurance & hospital affiliations
Knowledge of Medical Staff policy and procedures, JCAHO standards and other regulatory agency requirements
Maintains confidentiality of privileged information
Assure reappointment files are complete prior to being reviewed by the appropriate chairmen
Enters current demographic information into ECHO including additions/deletions to the Medical Staff as well as address/phone changes in an ongoing basis
Maintains expired licensures including: license, DEA, DPS and malpractice insurance (on-going)
Receives and records Medical Staff/Allied Health application fees
Responds to queries from other hospitals/institutions regarding Practitioners membership verifications
Receives, reads and sorts all incoming mail for the department
Maintains efficient and comprehensive working knowledge of the office software, including but not limited to, physician profile software
Ensures filing is maintained in a current and accurate manner
Assists the Director of Medical Staff with call schedules, meeting preparation and special projects when requested

Credentialing Specialist Resume Examples & Samples

Knowledge and usage of office equipment
Prepare files other documents, as requested, for review in an accurate, consistent, professional, and organized manner
Perform 3rd party verifications of submitted material as required by IPA Policies and Procedures
Document receipt of application materials and verifications in the credentialing system (Morrisey) (e.g. Texas Medical License, Malpractice Insurance, DEA, Board Certification, DPS, etc.). File copy in physician's file
Utilize Morrisey to run reports and make certain all certifications and other tracked information as required is up to date and accurate

Credentialing Specialist Resume Examples & Samples

At least 1 year of physician or ancillary/long term care credentialing preferred
At least 1 year of experience medical field preferred
Strong written and oral communication skills required
Must be able to work in a fast paced production environment

Credentialing Specialist Resume Examples & Samples

Gather all necessary Licensure and other Practitioner background items
Enter, maintain and update credentialing software program (OneAPP)
Enter, maintain and update Practitioners credentialing data storage drive
Process Credentialing to contracted insurances/networks for newly hired group Practitioners and ReCredentialing for existing group Practitioners as required
Process Credentialing to inpatient facilities (i.e. Hospitals/SNFs/Surgery Centers, etc.) for newly hired group Practitioners and ReCredentialing for existing group Practitioners as required
Conduct continuous compliance audits of existing Practitioners to maintain proper documentation
Perform primary and secondary source verifications of Practitioner’s credentials according to policy
Update appropriate outside Credentialing databases and websites as necessary to ensure information is current and accurate
Perform all other duties as assigned by Management
2 Years minimum Credentialing experience including Hospitals/SNFs/Surgery Centers

Provider Credentialing Specialist Resume Examples & Samples

Bachelor's Degree preferred or equivalent courses, training and experience, required
Strong computer and information management skills required
One to three years experience in a medical credentialing or provider enrollment environment (payer, IPA, managed care organization, medical group or institutional privileging) preferred
Knowledge of NCQA, physician payer credentialing, physician and allied provider privileging, and/or physician/provider and site regulatory licensing a plus
Prior experience with Managed Care Organizations, Centers for Medicare and Medi-Cal enrollment preferred
CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) preferred
Understand Medicare, Medicaid and commercial payer application process and EDI agreements
Fully proficient in online credentialing applications, such as CAQH, Pecos, NPDB, OIG, and AMA's profile service

CSS Credentialing Specialist Resume Examples & Samples

Perform primary (e.g., hospitals, licensing boards, etc.) and secondary source verifications of perspective providers' credentials with special emphasis on provider issues relating to malpractice claims, privileging, criminal concerns, license anomalies and discrepancies in education
Responsible for gathering and verifying physician information, compiling required documents, researching necessary information and verifying medical licenses
Compiles documents, researches and verifies provider backgrounds by contacting hospitals, licensing boards, medical schools, etc
Contacts or interviews provider peer references over the phone about the providers clinical performance skills
A minimum of 0-2 years’ experience in data entry, office administration management or medical financial experience. 0-2 years’ experience in credentialing/licensure verification/checks. Home health experience preferred. Requires excellent analytical skills, flexibility and ability to perform detailed follow through and prioritization

Credentialing Specialist Resume Examples & Samples

Perform the initial credentialing and recredentialing functions for employed and contracted practitioners, which may include collaborating physicians, Locum Tenens, nurse practitioners, registered nurses and social workers
Maintain timely and accurate data entry and periodically revise practitioner data in the credentialing database; maintain practitioner paper and electronic data files for practitioners; use the CAQH system to submit practitioner data as required by some client health plans to credential individual practitioners
Enroll practitioners with all appropriate client health plans; monitor and report on progress of each practitioner
Ensure all practitioners who require collaboration agreements are appropriately assigned to a collaborating physician and the agreement is executed by both parties; monitor and report progress of each practitioner
Ensure employed practitioners are enrolled under the professional liability insurance plan; monitor and report progress on each practitioner
Monitor expiring licensure, board and professional certifications and other expirable documents with practitioners within the prescribed time frames as outlined in the policies and procedures, assisting practitioners with timely renewal as appropriate and escalating to manager and field management as appropriate
Conduct sanctions and compliance monitoring and alert Manager of any undisclosed negative findings immediately
Assist traveling practitioners with obtaining new state licenses in areas identified by the clinical management team; monitor and report progress of each practitioner
Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services rendered; discover and convey problems to Manager

Credentialing Specialist Resume Examples & Samples

Execute licensure and credentialing processes for new and existing providers including but not limited to obtaining or requesting required documentation from various third-party sources and regular communication with appropriate state board representatives and the Field Management Team
Source and maintain up-to-date information regarding all new and existing state and federal requirements as they pertain to professional licensing and credentialing requirements, processes, schedules, etc
Report licensure and credentialing expiration dates and renewal requirements to the providers as well as the appropriate members of the Field Operations Management Team, Compliance & Risk Management, etc

MSN Credentialing Specialist Resume Examples & Samples

Building/maintaining relationships with field/branch employees
Accurate completion of employee files including pre-employment screenings, credentialing, and testing
Managing compliance in accordance with Joint Commission and MSN standards
Working with existing field/branch employees to keep documents current, active and compliant
Providing back-up support (with additional functions as deemed required) to help assure all operational needs are met
Computer proficient including Microsoft Office programs
Possesses capable, efficient customer service, organizational and human relations skills, along with the ability to create a sense of urgency to help expedite results
Knowledge of the medical/hospital/nursing profession a plus
High school diploma required; some college preferred
Two (2) years HR and or credentialing background preferred

Credentialing Specialist Resume Examples & Samples

Performs analysis and appropriate follow-up. Works with many individuals to acquire necessary materials and information, including, but not limited to: physicians, facility staff, professional staff and physicians office staff
Performs relevant data entry into the database to ensure consistency and integrity of the data
Processes appropriate queries for expired licensure, or any appropriate regulatory credentialing requirement and maintains documentation in the database

Credentialing Specialist Resume Examples & Samples

Possess thorough knowledge and full compliance with ValueOptions a Beacon Health Options Company and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations. Maintain strict confidentiality of member and provider information
Possess thorough knowledge of all facility program types commercially contracted by ValueOptions a Beacon Health Options Company to include full validation of compliance with clinical and credentialing criteria for such programs
Perform verbal, written, and on line verification of credentials including but not limited to medical experience, state licensure, prescribing certificates, education, modality, age ranges treated, accreditation status, Medicare/Medicaid certification, programs name/ address/ intake phone number, staff roster information, and (written) validation of program no longer offered
Prepare files for presentation to the National Credentialing Committee for approval, denial or recommendation for termination
Monitor work queue to ensure that applications are processed within a 30-day turn around time. Record and report work volume. Maintain production levels and quality scores in accordance with set standards for a Credentialing Specialist Level I specializing in Credentialing Review and Primary Source Verification Review
Manage and maintain the integrity of the provider credentialing database including data entry of credentialing information which requires full comprehensive and application of all applicable proprietary software applications (Connect products) in addition to utilization of multiple job aids and/or Access databases

Credentialing Specialist Resume Examples & Samples

Credentials and re-credential behavioral health providers using Cactus credentialing database
Works with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete
Performs primary source verification for individual credentialing & confirmation of facility accreditation and licensure
Tracks the recredentialing cycle of provider’s credentialing. Prepares files for monthly Credentialing Committee
Knowledgeable of current NCQA, CMS, DHCS, DMHC and other regulatory body’s credentialing standards
Previous data entry required. Microsoft Word, Excel, Outlook and Powerpoint experience required
Self-motivated, able to prioritize multiple assignments, excellent organizational skills, ability to track multiple projects/tasks and follow through as needed

Credentialing Specialist Resume Examples & Samples

Performs and oversees hospital credentialing process for all providers at contracted facilities. Primary contact for medical staff offices of assigned sites. Initiates process of credentialing at client hospitals (requesting application) and follows through on entire process to ensure providers obtain privileges prior to working their first shift. This involves reviewing files to ensure application is completed correctly and that the proper documentation is provided to client hospital, following up with client hospital medical staff office and providing assistance to resolve issues in order to facilitate the credentialing process
Adheres to internal and contracted facility procedures of credentials verifications (I.e. license & data bank queries)
Initiates obtaining professional liability insurance certificates for providers
Maintains credentialing database; performs all required data entry to ensure the completeness and accuracy of the database, responsible for ensuring all credentials on file are current and that copies have been provided to client hospital. Includes running monthly credentialing expiration reports that notify providers of documents that have expirations that are pending
Provides status reports on pending providers
Keeping up to date with rules and regulations with various licensing agencies to ensure compliance
Maintains highest level of confidentiality related to provider issues in performing the above tasks
Performs other related duties as required and assigned

Credentialing Specialist Resume Examples & Samples

Adhering to established credentialing guidelines completes in-depth review and analysis of practitioner’s application and accompanying documents ensuring applicant meets facility guidelines and eligibility. Examines researches, enters data, sets up files and gathers all information necessary to process information received from providers to support and complete the initial, reappointment and expirable credentialing process. Utilizes various websites, contacts educational facilities and professional references to verify credentials. Ensures compliance with facility Medical Staff Bylaws, Rules and Regulations, policies and procedures for hospital clients and EmCare
Extensive and frequent verbal and written communications with Clinicians, Medical Staff Offices, educational facility, state licensing boards, professional references and internal company staff, requiring professionalism and tact, to attain or provide all needed information quickly in order to expedite the credentialing of Clinicians. Provides excellent customer service in accordance with EmCare’s customer service standards to all internal and external parties
Achieves compliance with Credentialing Department metrics and performance standards by adhering to the Credentialing process and documenting accurately in company databases. Accurately maintains systems data bases and spreadsheets to track, follow-up and disseminate hospital privilege status to other department in a timely manner. May be involved in generating and managing various reports for management, implementing best practices and working on projects as assigned
Attend and participate in all team related meetings; participating in developing and implementing company-wide and team goals; participates in problem-solving and decision making; positively supports and adheres to corporate and division management decisions, being flexible and adaptable to change, establishing trust and respect for other team members and completing training as required
Credentialing experience preferred, but will train the right individual
Knowledge of related credentialing, privileging, accreditation and certification procedures, requirements and hospital operations preferred
Experience with State and Regulatory agency requirements as it relates to healthcare credentialing guidelines preferred
Excellent verbal and written communication skills are essential. Able to communicate and present information to a wide variety of parties effectively

Credentialing Specialist Resume Examples & Samples

A comprehensive benefits package
A clear career path with opportunities for advancement
A supportive, fun, team environment

Credentialing Specialist Resume Examples & Samples

File Preparation
As a member of an integrated team, open and process practitioner credential, quality, provider assessment files in compliance with KPNW Credentialing and Recredentialing Policies and Procedures and QRM desk procedures. Communicate effectively with NWP and KFHP to obtain human resources and provider contract information as inputs to the credentialing and assessment processes. Mail credentialing application packets to applicants and follow-up, as needed. Investigate record of previous KPNW credentialing. Assure paper file in standardized order. Maintain electronic file record accurately, timely, with agreed formats for style, case, and professional language. Assess need for delineation of privileges; facilitate applicant and chief to achieve accurate completion of delineations. Assure complete, rapid and service-oriented initial practitioner credentialing, privileging, and provider assessment within constraints of due-diligence credentialing practices and KPNW Policies and Procedures. Audit files prior to presentation to assure completion and compliance. Issue status reports to NWP and KFH/P on progress and potential credential date. Assure complete, accurate, timely, service-oriented reappointment and reassessment within constraints of sound credentialing practices and KPNW Policies and Procedures
KPNW Credentials Committee and Provider Assessment Committee
Prepare credential, assessment, and quality paper and electronic files for chief of service, Committee peer reviewer, and Committee meeting. Identify and flag issues of concern, work with chiefs and peers to pursue information. Prepare lists, reports, documents, agendas for meetings. Prompt chairs and presenters. Track open issues, follow-up on action items. Record meetings accurately, discreetly, timely and in professional minute-style. Distribute minutes confidentially and maintain survey-ready. Assure tracking, follow-through, stamping and closure of paper and electronic files. Report to Executive Committees and Boards of Directors accurately and timely
Audits and Surveys
Maintain documentation and files survey-ready. Prepare KPNW for Internal and external audits and surveys. Meet with auditors and accreditors, respond to questions, facilitate file reviews. Know accreditation standards; achieve and maintain accreditation status. Perform/participate in KPNW audits of delegated entities and delegate’s audits of KPNW. Audit files and minutes, write reports and responses to audits. Present audit results and recommendations to Credentials Committee. Monitor and assess compliance with Credentials MOUs, identify opportunities for improvement, and ensure adequate follow-up is received as requested
Policies, Procedures, Forms
Identify need for, write, flow diagram and maintain regional Credentialing and Recredentialing Policies and Procedures, desk procedures, and credentialing/organizational assessment forms that meet the standards of state and federal legislation and accrediting body standards. At least annually review and update. Link policies, procedures, forms and practices in seamless flow. Coordinate with bylaws, Medical Directors Quality Committee standards, internal and external customers. Maintain and utilize as standard operating procedures and to direct processing of special situations. In-service other departments/practitioners affected
Support internal and external customers created by credentials delegation agreements. Act as NWP “office manager” facilitating document flow for KPNW practitioners. Act as “Credentials Verification Organization” and/or “Primary Admitting Facility” in relationships with delegates: provide reappointment packets to plan hospitals in accordance with MOU; pursue documents; generate and distribute rosters; provide copies of licenses, insurance, malpractice claims, CMEs. Communicate accurately, diplomatically—within procedures related to confidentiality and protection of peer reviewed material—with previous and current affiliations and medical boards across the country. Communicate with internal and external customers responsively to strengthen and maintain working relationships and delegation agreements
Assess potential to delegate credentialing, assessment, or any component thereof. Apply KPNW Policies and Procedures and accreditation standards to potential situation, arrive at decision, make recommendation to NWP, KFHP, Contracts Departments. Enter delegation information into paper and electronic files. Facilitate win-win relationships with delegates and potential delegates
Orientation
Orient new practitioners, staff from input and output departments, chiefs of service, Quality assurance representatives, Committee peer reviewers, plan hospital partners, service managers, and committee secretaries to the practitioner credentialing and provider assessment processes. Train, educate, elicit support, and cooperation
Performance Reports
Audit and track work ongoing. Complete accurate and timely reports to be used for reporting purposes to Northwest Permanente, the Regional Operations Group and Boards of Directors summarizing monthly activity. Participate in Healthcare Data and Information (HEDIS) data-gathering and inputting
Minimum one (1) year of experience in medical staff credentialing and privileging including assembly of quality files
Minimum two (2) years of experience credentialing
Previous experience preparing for and participating in JCAHO, NCQA or other external surveys
BA/BS degree or equivalent education and work experience
NAMSS CPCS or CPMSM certification maintained or willingness to pursue certification as at earliest possible time and maintain
Working knowledge of NCQA and JCAHO medical staff, credentialing and organizational assessment standards
Working knowledge and experience of office automation system, Windows, Excel, Access and credentialing software
Customer service oriented verbal and written communication skills

Credentialing Specialist Resume Examples & Samples

Completes all paperwork in relation to credentialing process, i.e. checklists, department approvals, approval letters, etc. and uploads forms into Cactus
Processes all temporary privileges in accordance with Medical Staff Bylaws
Enters clinical privileges into Cactus database for all privileged practitioners
Maintains Meditech Provider Dictionary in accordance with Corporate Policy CSG.QS.002
Maintains Cactus credentialing database by entering credential dates, clinical privileges, approvals, contact logs, etc
Enters all requests for access into eSAF program for physicians and Advanced Practice Professionals

Credentialing Specialist Resume Examples & Samples

Gathers data, reviews for completeness and accuracy, analyzes potential problems and recommends appropriate actions. Monitors timeliness and receipt of information and follow up as needed
Identifies questionable and highly sensitive information and refers to appropriate sources for further research
Enters credentialing data into system and tracks and maintains provider information
Performs general office duties such as filing, duplicating, sorting, mail distribution, etc
Works with internal department to exchange provider information and follows up on inconsistencies
Identifies procedural and systems problems and brings them to Supervisor's attention; makes recommendations where appropriate
Maintains the Professional Office Review database to track activities of office review and medical record review
May review reports from regulatory and controlling oversight agencies. May summarize provider files to facilitate committee review or prepare detailed documentation related to formal reviews

Lead Credentialing Specialist Resume Examples & Samples

Two years business or technical college or 2 years of experience in a hospital or health plan credentialing position; OR current CPCS or CPMSM certification and 2 years of experience in a hospital or health plan credentialing position
Two years experience in a hospital or health plan credentialing position
Excellent organizational skills, attention to detail, written and verbal communication skills
Must have ability to use independent judgement to perform a wide variety of tasks in a professional manner
Varied PC, database and work processing ability

Credentialing Specialist Resume Examples & Samples

Completing physician credential documents
Calling in payers to confirm physician has been added to their group
Update mailing address

Echo Credentialing Specialist Resume Examples & Samples

3-5 years supporting the Echo Credentialing or a credentialing software equivalent and have successfully added new facilities from legacy systems
Must have an understanding of the Extract, Transform, and Load (ETL) process
Can manage complex SQL queries including sub-queries and joins
Able to analyze current business processes and standardize legacy data to comply high level of accountability and follow-through
Must be able to work with minimum direct supervision
Able to work in a deadline-driven, detailed-oriented environment

Credentialing Specialist Resume Examples & Samples

High School Diploma OR GED required
Two(2) years of hospital or CVO experience in credentialing preferred
Certified Professional Credentialing Specialist (CPCS) certification preferred

Credentialing Specialist Resume Examples & Samples

Review new applications and supporting documents in a virtual environment and apply policy and criteria required for credentialing processing
Perform all required primary source verifications
Contact hospitals, licensing agencies, malpractice carriers, and medical schools to obtain credentialing verifications
Maintain and update credentialing database records
Review malpractice history, regulatory and disciplinary action reports issued by state and federal agencies invoking appropriate processes as defined in policies and procedures
Review the CAQH system and download applications or supplemental documents as appropriate
Maintain electronic provider files
Demonstrate knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.)
Required 1+ year of experience in a hospital, provider or managed care setting
Required 2+ years of experience in a customer service or healthcare related position
Preferred Other Certified provider credentialing specialist or directly related or equivalent work experience

Credentialing Specialist Resume Examples & Samples

The Credential Specialist is responsible for communicating with and assisting facilities and staffing vendors in achieving and managing full candidate compliance per Joint Commission standards and / or client specific requirements
Secure full compliance for all employee starts with follow up on all compliance requirements to ensure employee credentials are up to date at all times
Ensures all expiring documents are communicated to our agency staff and ensure that updated documents are obtained
Strong trouble shooting skills and abilities
Possess excellent interpersonal communication skills with the ability to build successful customer relationships

Credentialing Specialist Resume Examples & Samples

Maintain electronic credentials files that meet all regulatory agency requirements
Serve as the person responsible for processing credentials files that contain dated, accurate approved content on time, verify professional history, communicate the status directly to providers and administrators and meet regulations
Monitor all aspects of the file process and evaluate for a total picture of the provider’s background
Process initial and re-credential files for the Medical Staff and Allied Staff within Allina

Credentialing Specialist Resume Examples & Samples

Perform verbal, written, and on-line verification of credentials for providers, medical directors, licensing agencies, accrediting bodies and other entities including, but not limited to: medical experience, state licensure, prescribing certificates, education, modality, age ranges treated, accreditation status, Medicare/Medicaid certification, programs name/ address/ intake phone number, staff roster information, and (written) validation of program no longer offered
Monitor work queue to ensure that acknowledgments are sent to providers within five (5) day turn-around time and email inquiries are sorted and assigned to the Reviewer on a daily basis. Record and report work volume. Maintain production levels and quality scores in accordance with set standards for a Credentialing Specialist Level III specializing in Credentialing Review and Primary Source Verification Review
Review and process change of address requests which consists of verifying the accuracy of the required forms and documentation i.e. license, permits, etc
Computer literacy and intermediate use of Microsoft office programs (Internet, Outlook, Word and Excel). Operational knowledge working with fax machines, copiers, and other office machines
Possess thorough knowledge and full compliance with Beacon Health Options and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations
Able to work in a production based environment and meet production goals
Demonstrate working knowledge of medical terminology; excellent oral and written communication skills; and the ability to communicate with stressful callers maintaining calmness, assertiveness and diplomacy

Credentialing Specialist Resume Examples & Samples

Obtains all applicable affiliations by utilization of verification software/databases as well as approved verification sites via the internet primary source information and references
Obtains all applicable education by utilization of verification software/databases as well as approved verification sites via the internet primary source information. Must remain professional throughout the call
Sends appropriate communication and provides follow up to practitioners
Ability to follow accounts through to completion
Record all incoming mail/supporting documentation in credentialing software system
Location/Facility – Baylor Corporate Office
Medical Staff Services Certification
Certified Professional Medical Services Management
Certified Provider Credentialing Specialist
Associates Degree Preferred

Credentialing Specialist Resume Examples & Samples

Credential & Re-credential behavioral health providers & facility organizations (hospitals, mental health centers, etc.) using Beacon’s Network Connects Credentialing System
Perform verbal, written & on-line primary source verification for individual & facility organizations including but not limited to, state licensure, prescribing certificates/registrations, education, training & certification verification, accreditation status and exclusion data-base checks
Monitor work queue to ensure applications are processed timely within expected turn around times while maintaining quantity & quality that meets or exceeds internal department standards
Computer literacy & intermediate use of Microsoft office programs (Internet, Outlook, Word & Excel) as well as Adobe PDF Creator. Optional knowledge working with fax machines, copiers and other office machines
Ability to work in a production based environment & meet production goals
Must possess a professional demeanor, strong written and oral communication skills, strong computer skills, and the ability to learn Beacon’s internal systems

Credentialing Specialist Resume Examples & Samples

Accurately enter information into Network Connect (NWC) for all potential network providers and/or existing providers being re-credentialed for the network
Complete provider’s TRICARE Certification for eligibility
Ensure provider applications are loaded into NWC and a receipt of application letter is returned within 5 business days of the receipt date of the application
Inventory should be reviewed daily, ensuring that applications are assigned and scrubbed for missing information within 15 days of receipt
Process provider applications using paper base, electronically base and through CAQH
Must demonstrate proof of U.S. Citizenship. The Department of Defense Contract requires U.S. citizenship for this position as well as a successful background investigation based on the completion of the Questionnaire for Public Trust
Excellent oral and written communication, interpersonal skills and customer orientation

Credentialing Specialist Resume Examples & Samples

Required: Excellent written and verbal communication skills
Required: Proficiency with basic data entry, database software, and general computer use
Required: Ability to type at least 35 wpm
Required: Ability to professionally adapt to a rapidly changing environment and rule set
Preferred: Knowledge of NCQA, CMS, and/or managed care credentialing criteria
Preferred: Software proficiency with Microsoft Word, Microsoft Outlook, Visual CACTUS, and/or Laserfiche

Credentialing Specialist Resume Examples & Samples

Possess thorough knowledge and full compliance with Beacon Health Options and current accreditation standards (i.e. NCQA, JCAHO, URAC, CVO, CMS) for Managed Behavioral Healthcare Organizations. Maintain strict confidentiality of member and provider information
Possess thorough knowledge of all facility program types commercially contracted by Beacon Health Options to include full validation of compliance with clinical and credentialing criteria for such programs
Ability to learn quickly and a keen eye for details, analytical and problem solving skills, the ability to withstand varying job pressures and to meet deadlines and the ability to handle multiple tasks at one time with minimal supervision
Ability to work in a production based environment and meet production goals
Displays flexibility in work assignments and a positive attitude

Credentialing Specialist Resume Examples & Samples

Completes and maintains clinicians privileges and hospital appointments and reappointments
Maintains and updates credentialing reports
Research and resolves all credentialing and payer enrollment issues
Participates, presents and attends professional/departmental meetings
Works in collaboration with the Contracting Department, Revenue Operations, Clinical Operations and other areas on issues to improve processes and outcomes
Coordinates Peer Review activities and processes in compliance with all applicable requirements in conjunction with the Peer Review Committee
Ability to communicate effectively; Ability to work independently; Skilled in a variety of software applications

I.T Credentialing Specialist Resume Examples & Samples

Must have strong customer service and communication skills
Demonstrated ability to meet regular time and attendance requirements
Provides physician credentialing support utilizing the clinical application HCHB and working as part of the team that maintains the company's IS Service Desk
Answers first level support phone calls, email and web requests
Researches, resolves, and responds to end-user/problems/questions received via email, telephone calls, callbacks, web requests or escalations, and provides support on technology platforms, in accordance with current standards and service levels
Participates in team projects as required

Credentialing Specialist Senior Resume Examples & Samples

Requires a H.S. diploma; 4-5 years credentialing experience; or any combination of education and experience, which would provide an equivalent background
CPCS or CMSC preferred
East Coast location preferred

Credentialing Specialist Resume Examples & Samples

Proficient in Microsoft Office. Knowledge of Outlook and database systems preferred
Excellent communication skills both verbal and written with a willingness to provide superior customer service
Prior experience in a business office environment, preferably in a staffing, medical or quality assurance capacity
High School Diploma or equivalent, some college preferred

Credentialing Specialist Resume Examples & Samples

1 to 3 years’ experience in Credentialing/MSO office
Highly motivated to achieve desired goals and objectives
Creative problem-solving and risk-taking skills
Superior leadership skills with enthusiasm, initiative and a passion for result
Intermediate knowledge of Microsoft Office
Ability to prepare and write reports, summaries of work/work projects
Ability to prioritize workload and meet strict deadlines
Ability to work in a fast-paced and fluid environment
Strong problem-solving skills and attention to detail
Ability to communicate clearly and concisely across multiple levels within the company

Credentialing Specialist Resume Examples & Samples

Ensure that appropriately completed credentialing applications are submitted to every contracted payor for each Lancaster General Health employed Physician and Practitioner (CRNA, CRNP, Physician Assistant, etc.) in a timely fashion
Respond timely to all written, verbal, and electronic payor requests regarding missing or additional information necessary to complete the credentialing/re-credentialing process for each Physician/Practitioner
Maintain the accuracy of Physician/Practitioner payor credentialing records in OneApp Pro, CAQH, PECOS, PROMISe, and other formats accepted by contracted payors
Provide periodic Professional Billing Services/Practice updates with regards to credentialing status of any new Physician/Practitioner
Research and respond to all inquiries from Professional Billing Services/Practice staff related to claims denied or underpaid for “provider not credentialed” and other related set-up issues when internal records indicate payor approval by date of service

Credentialing Specialist PRN Resume Examples & Samples

Basic computer knowledge with knowledge of word processing and database management
Knowledge of medical staff procedures, minute taking and medical staff office processes
Knowledge of MD Staff software a plus
Ability to learn new software programs as they are implemented to better facilitate processes

Credentialing Specialist Resume Examples & Samples

1+ year of Medical staff Credentialing experience
Knowledge of Credentialing procedures, policies and terminology
Solid analytical and problem solving skills

Credentialing Specialist Resume Examples & Samples

Responsible for verifications for medical staff and allied health professionals initial appointments, provisional reviews, reappointments and privilege delineation
High School Diploma required. Associate’s Degree preferred
1 year of hospital or managed care credentialing experience required
High level of energy to work in a fast paced environment often including time deadlines, frequent interruptions, multiple demands and multi-tasking
Working knowledge of State and Federal law relating to due process and provisions of the Health Insurance Portability and Accountability Act if 1996 and all applicable standards

Associate Credentialing Specialist Resume Examples & Samples

Verify all related specialty credentials, including but not limited to medicare, education, training, licenses, and malpractice/professional liability insurance as applicable
Enter all provider information and primary source verification data into the related database
Create and maintain provider files in compliance with the organization’s policies
Assist in preparing all required materials for FHP’s Credentialing Committee
Abide by all policies, procedures, and work instructions for the credentialing function of the Medicare Advantage plan
Assist in goals and performance standards management
Ensure data integrity is maintained in related credentialing database and core system records
Improve efficiencies and service provided while reducing costs
Assist with preparing files and materials for internal and external regulatory audits
Attend trainings and reference materials including content, work instructions, and tools
Obtain knowledge of credentialing regulatory and accreditation requirements (CMS, NCQA, etc.)
Perform monthly monitoring
Prepare for internal and external audits
Perform quality checks

Credentialing Specialist Resume Examples & Samples

Prepare and maintain reports of credentialing activities such as payer enrollment statuses, provider credentials, and client demographic data
Create and carry out enrollment processes in relation to physicians and other ancillary healthcare professionals as it relates to participating with insurance companies
Perform data entry as necessary within the designated provider enrollment software
Gather and maintain provider credentials and documents within a secure network location
Manage initial payer enrollments for new providers from start to finish
Monitor re-credentialing dates for all commercial and government payers to ensure timely follow up and perform re-credentialing enrollments as needed
Create and maintain provider CAQH (Council for Affordable Quality Healthcare) accounts
Establish strong relationships with insurance provider relations representatives
Communicate updates to key stakeholders regarding provider enrollment statuses
Associate’s Degree or Equivalent
Certification as a Credentialing Specialist such as CPCS
Experience working with the provider software Echo OneApp
Experience as a Credentialing Specialist in an ambulatory or clinical setting

Credentialing Specialist Resume Examples & Samples

Experience in managed care role, centralized credentialing office or related healthcare environment
Requires high proficiency with all Microsoft Office apps such as Outlook, Word and Excel
Knowledge of CAQH application
Ability to work in deadline-intense environment
Problem solving and customer service abilities
Minimum HS diploma or GED required

Credentialing Specialist Resume Examples & Samples

Performs Primary Source Verification for individual credentialing & re-credentialing
Maintains credentialing management documents
Organizes and maintains credentialing files
Works with Network Contracting and Provider Relations departments and other Beacon staff to ensure follow up with providers when applications are incomplete
Tracking of all credentialed providers for the purpose of re-credentialing
Ensures that all providers are re-credentialed or terminated in a timely manner
Accurately enter information into Beacon’s credentialing system Cactus
Working Knowledge of NCQA credentialing and re credentialing standards
Assists with the revisions and/or development of policies and procedures
Prepares files for CMO and Credentialing Committee
Effective verbal and written communications, as well as an ability to be clear and concise in all communications
Proven ability to work both independently and in a cross-functional team structure
Strong organizational skills including the ability to manage concurrent tasks and assignments with competing priorities and deadlines

Credentialing Specialist Resume Examples & Samples

Credential and re-credential behavioral health providers and facility organizations (hospitals, mental health centers, etc.) using Beacon’s NetworkConnect credentialing system
Perform verbal, written and on-line primary source verification for individual and facility organizations including but not limited to, state licensure, prescribing certificates/registrations, education, training and certification verification, accreditation status and exclusion data-base checks
Accurately and timely perform data entry of all primary source verifications and select provider demographic and practice location information into Beacon’s NetworkConnect credentialing system
Stay current with knowledge of NCQA credentialing standards
Credential and prepare credentialing and recredentialing files for weekly Medical Director submission and bi-weekly National Credentialing Committee submission
Monitor work queue to ensure applications are processed within expected turnaround times
Meet or exceed production and quality standards
Display a positive, constructive, and helpful demeanor
2 years’ experience in insurance, medical, healthcare or related field required
Professional demeanor, strong written and oral communication skills, strong computer skills, and the ability to learn Beacon’s internal systems
Ability to learn quickly
Detail-oriented, analytical, highly organized and possessing problem-solving skills
Ability to manage varying job pressures, and meet deadlines and handle multiple tasks simultaneously with minimal supervision
Ability to work in a production environment and meet production and quality goals
Computer literacy and experience with Microsoft office programs (Outlook, Word and Excel), and internet searches. Knowledge working with fax machines, copiers and other office machines

Credentialing Specialist Resume Examples & Samples

Prior experience required in medical staff/provider services project management and administrative support
Must possess computer skills in database management, practice management systems, spreadsheets, graphics, and word processing (Microsoft applications preferred)
Strong customer service, written communications skills
Equivalent education or Associate’s or Bachelor’s degree in Health Business Administration

Credentialing Specialist Resume Examples & Samples

Education: High School or equivalent; Associates’ degree preferred
Experience: One year of healthcare or managed care related experience preferably in hospital or health plan credentialing
Effective analytical skills with the ability to assess compliance, record, analyze, and interpret data into meaningful formats
Basic computer skills: Microsoft Office, Word and Excel
Basic understanding of credentialing Joint Commission, NCQA, and URAC accreditation standards
Demonstrated ability to work both independently and collaboratively with a team and with multiple departments while being able to take full responsibility for tasks
Processes provider applications and re-applications including initial mailing, review and loading. Also coordinates the distribution of emails, mail outs or other documents to customers
Assist in the implementation of procedures and activities related to the credentialing, re-credentialing and privileging of network providers
Maintains provider profiling system and communicates with providers by phone and mail regarding credentialing status
Tracks, maintains and updates licensure: DEA and state narcotics certification or other expiring credentials. Coordinates with physician office to obtain expiring documents
Answers internal and external customer phone calls. Provide physicians with credentialing application status updates in a timely and professional manner. Escalate customer concerns appropriately
Monitors physician sanction sources and board actions. Escalates alerts appropriately
Performs basic data entry on credentialing applications

Credentialing Specialist Resume Examples & Samples

General clerical duties including copying, faxing, and mailing
Maintain electronic and hard copy filing system
Retrieve documents from filing system
Handle requests for information and data
Resolve administrative issues and inquiries
Prepare and modify documents, including correspondence, presentations, reports, drafts, memos, and emails
Prepare agendas for meetings and prepare schedules
Record, compile, transcribe and distribute minutes of meetings
Assures all data is entered into system and/or tracking spreadsheets in a timely and thorough manner per policy and procedures
Tracks and ensures that all licenses and certifications are current
Prepares accurate and timely reports for internal staff
Interfaces with Senior Management, Billing, IT, Accounting and Patient Accounts Departments
Demonstrates professional conduct and complies with company and departmental policies and procedures
Maintains systems to identify medical staff members and their clinical privileges; prepares and maintains other related records and reports
Monitors and suggests revisions to credentialing, onboarding, and processes as needed
Adheres to Adeptus Health attendance policy as outlined in the Employee Handbook
Proficiency with standard office equipment
Experience with clerical and administrative procedure such as filing and record keeping
Knowledge of principles and practices of basic office management
Must have a clear and pleasant speaking voice
Must be able to work independently, and prioritize workload to meet established goals and timelines
Must have excellent organizational skills and the ability to manage multiple projects simultaneously
An understanding of primary source verification of healthcare provider credentials
Must have exceptional verbal and written communication skills
Experience in provider credentialing
Advance Microsoft Office Suite skills

Credentialing Specialist Resume Examples & Samples

Two years of credentialing or privileging in a health care environment is required
One year of experience in a managed care setting
Must be proficient with Microsoft Office, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies
Must have working knowledge of NCQA standards. CPCS or CPMSM certification preferred

Credentialing Specialist Resume Examples & Samples

High school diploma or general education degree (GED) required; college certificate or degree preferred
1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
#LI-MR1

Credentialing Specialist CVS Resume Examples & Samples

High school diploma or general education degree (GED) required; college certificate or degree preferred. 1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
Detailed oriented, organized with strong sense of ownership and responsibility. Must have ability to use independent judgment to manage and prioritize the multiple tasks and deadlines in a professional and positive manner. Attention to details required
Intermediate to advanced PC skills: Web proficiency / internet; database management; MSWord required. Experience in MD-Staff or Morrisey databases, MSExcel and MSAccess preferred
#LI-MR1 0

Credentialing Specialist Resume Examples & Samples

O High school diploma or general education degree (GED) required; college certificate or degree preferred. 1-2 years’ experience in healthcare, credentialing/medical staff office, or managed care credentialing experience preferred
O Detailed oriented, organized with strong sense of ownership and responsibility. Must have ability to use independent judgment to manage and prioritize the multiple tasks and deadlines in a professional and positive manner. Attention to details required
O Intermediate to advanced PC skills: Web proficiency / internet; database management; MSWord required. Experience in MD-Staff or Morrisey databases, MSExcel and MSAccess preferred

Credentialing Specialist Resume Examples & Samples

Previous experience of at least three years may be substituted for education
Valid certification as a Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM)
Certification must be passed within two years of becoming eligible for exam

Credentialing Specialist Resume Examples & Samples

Continuous monitoring of licensure to ensure Clinical and Pharmacy services are in compliance with existing and/or new licensing standards
Maintains documents for licensing compliance including Clinical and Pharmacy Services SOPs and Work Instructions
Responsible for document management on indicated database
Provides feedback to Clinical and Pharmacy leadership on documents that need revision
Responsible for tracking expiration dates for all new and existing nursing and pharmacy licenses within the organization
Responsible for tracking new license applications to ensure timely submission per SOP
Responsible for utilizing all technology and resources effectively and efficiently
Works directly with Finance for check requests as needed per state board requirements
Recommends training opportunities to improve operational performance through business level data analysis
Guides and participates in trending activities that support the establishment of quality metrics, and continual process improvements across the organization
Serve as subject matter expert on state board license and Pharmacist in Charge requirements
The role will be dedicated to initiatives including maintenance and compliance with all licensing standards
Develops, writes, and communicates guides for licensees as they move towards their required licensure
Quality and/or process improvement experience preferred
Requires broad training in fields such as business administration, accountancy, sales, marketing, computer sciences, or similar vocations generally obtained through completion of a four year Bachelor's degree program or equivalent combination of experience and education
Proficiency in MS Outlook, Excel, Word, and PowerPoint
Establish and maintain relationships with business partners and other licensure stakeholders. Provide technical advice and direction to business partners related to licensure activities
Assess needs from State Board of Nursing and Pharmacy Boards (gathering, analyzing, documenting, and managing changes)
Analyze current processes to understanding their strengths and weaknesses to determine opportunities for improvements
Project management/process improve experience (with ability to manage competing priorities)
Outstanding written and oral communication, including the ability to communicate effectively to multiple levels of the organization at one time
Ability to work with data to present information, draw conclusions, and make recommendations to business leaders
Ability to balance multiple priorities at one time

Provider Enrollment & Credentialing Specialist Resume Examples & Samples

Manage and complete Provider enrollment applications
Extensive follow-up to ensure Provider numbers are established and linked to the appropriate group entity in a timely manner
Understand specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation (DEA, CV, etc.), and regulations
Maintain documentation and reporting regarding Provider enrollments in process
Retain records related to completed Provider enrollments
Work closely with physician recruitment and corporate resources to expedite completion of enrollment requirements including obtaining signatures
Maintain Provider enrollment information within the credentialing database (Vistar)
Establish close working relationships with credentialing coordinators, contracting department, and payer contacts
Consistently demonstrate competency in job required skills
Contribute to a pleasant and comfortable environment; demonstrate respect and maintain patient’s dignity and confidentiality

Credentialing Specialist Resume Examples & Samples

Associate's degree, or high school diploma/equivalent
1+ years of data entry, customer service, medical office, provider data management, credentialing or healthcare operations i.e. claims processing, billing, provider relations or contracting experience, preferably in a managed care or insurance environment
Ability to thrive in a fast-paced production environment while maintaining quality

Credentialing Specialist Resume Examples & Samples

Entering provider and contract information into database
Scan documents into appropriate electronic storage locations
Performs miscellaneous job-related duties as assigned
Work closely with internal and external sources to expedite completion of forms and requirements and
A High School diploma or its equivalent is required with 3-5 years' experience that is related to the duties and responsibilities; one year of related experience in a health care setting is preferred
An Associate's degree in business or related field preferred
Professional Association; Affiliation and participation with the National Association Medical Staff
Familiarity with Microsoft programs, including WORD, ACCESSand EXCEL is required
Experience with developing reports from database applications such as ACCESS is required
Familiarity with use of the Internet and e-mail applications is required
The position involves daily contact with physicians, business executives and the public; the ability to interact in a professional and courteous manner is required
The ability to communicate effectively both verbally and in writing is required
A high level of initiative and sound judgment is required
Ability to manage multiple tasks in a fast paced environment is required
Ability to work as a member of a team is required
Ability to adjust to changing priorities on short notice is required

Credentialing Specialist Resume Examples & Samples

Utilizes all available resources to reach sound decisions
Assumes responsibility for problems and initiates actions to solve them
Work with others toward shared goals including participation in department problem-solving and improvement activities
Bring issues related to the credentialing and/or recredentialing process to the attention of management in a timely fashion
Foster change initiatives to ensure continuous performance improvement and service excellence
Participate in Joint Commission preparation and NY State DOH Survey
Participate in Managed Care Audits
Assist in preparation and mailing of correspondence required for Credentialing, when necessary
Provide support services and act as back up to clerical staff when necessary
With appropriate training, accept additional related duties, as needed
Participate in education programs, in-service meetings, workshops, conferences, and committees
Keep abreast of current literature and professional trends
Review and understand the Medical Staff Bylaws of each CHS Facility
Review and understand the Joint Commission Standards
Review and understand the NCQA Standards
5 years of Credentialing experience in a hospital setting
Proficient in Microsoft Office, including Word and Excel
Must have the ability to prioritize and have good listening, written and oral skills
Excellent customer service, oral/written communication, interpersonal, and organizational skills, Well versed in the use of the Cactus Database
CPCS (Certified Provider Credentialing Specialist)
Credentialing and medical staff services experience preferably in a hospital setting
Proficiency in Microsoft Office is required. Advanced knowledge of Word & Excel required
Excellent customer service, oral/written communication, interpersonal, and organizational skills
Knowledge of Cactus a plus
Knowledge or experience with credentialing processes desirable

Credentialing Specialist Resume Examples & Samples

Basic knowledge of the health care industry including knowledge of health care acronyms, Medicare, Medicaid and Managed Care
Ability to organize and prioritize work with multiple and competing priorities
Ability to research and perform root cause analysis to issues
Ability to develop and maintain and effective working relationship with all customers (internally and externally)
Proficient use of Microsoft Office applications and internet resources

Credentialing Specialist Resume Examples & Samples

Perform provider credentialing/qualifying process to ensure all requirements are met in accordance with credentialing requirements prior to presentation to the client hospital
Notify and assist providers in renewing expiring credentials such as licensure, BLS, ACLS, ATLS, PALS, as required by contract while ensuring that all credentials are current at all times
Ensure that all credentials files are current and complete pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage, DEA and other pertinent information, per HPP and/or client facility policy and procedures
Assist in the credentialing process by entering/logging/scanning information into credentialing system for initial, updating, and add on applications and maintenance processes
Acts as point person for completing and ensuring compliance and delivery of required information to providers in a timely manner
At least 1 year experience in a healthcare environment (preferably in credentialing)
Experience providing executive support
Proficiency in Microsoft Office

Credentialing Specialist Resume Examples & Samples

Reviews completed files with management in accordance with established schedules
Maintains credential records
Initiates correspondence to providers, users, health plans and others as necessary to obtain requisite credentialing information
Certification as a Provider Credentialing Specialist (CPCS) from the National Association of Medical Staff Services, preferred
Excellent customer service skills and orientation

Credentialing Specialist Resume Examples & Samples

9 months credentialing, provider services production or customer service experience
PC experience to include Windows, Word, Excel, and business databases
Organizational skills and decision-making ability

Credentialing Specialist Provider Enrollment Resume Examples & Samples

Associate Degree required, Bachelors Degree preferred
3 – 5 years experience in an administrative support capacity in healthcare at the advanced level required; 5 years experience working within the insurance agency, hospital or other healthcare setting with responsibilities related to credentialing or provider enrollment preferred
CPCS or willing to obtain within two years
Understanding of the credentialing and privileging process for health plans
Computer Proficiency
Microsoft Office to include Word, Excel, Power Point
Ability to work with an application specific database
Customer service orientation
Ability to work well within a team structure
Knowledge of NCQA and delegated credentialing requirements

Credentialing Specialist Unc Omss Resume Examples & Samples

Coordinates the administration and scheduling of a variety of professional meetings, seminars, or conferences. Coordinates the planning and logistical arrangements for special events. Maintains detailed calendars and records and confirms logistics associated with events. (O)
Prepares a variety of office documents, records, reports, charts and graphs. Determines some format, content and presentation. Gathers, analyzes and compiles information into report format. (O)
Provides leadership and guidance to co-workers. (O)
Responds to inquiries with written explanation by interpreting established policies and procedures. Coordinates mail screening and distribution. (O)
Serves as primary resource with internal and external contacts on administration of office program and/or program policies and

Credentialing Specialist Resume Examples & Samples

High School diploma/GED
Minimum of three (3) years of experience in multi-specialty-provider credentialing encompassing government, commercial and other insurance products, with increasing responsibility during that time period, or related experience
Credentialing Specialist (CPCS) Certification or equivalent experience
Must possess strong analytical skills. Excellent communication and organizational skills required. Ability to work independently, manage multiple priorities, and meet established deadlines. Leadership, communication, customer service, multi-tasking, and computer skills are necessary for this position. Experience dealing with clinical staff as well as financial support staff required. Must be a team player

Credentialing Specialist Resume Examples & Samples

Requires High School diploma / GED
Provider Credentialing, enrollment, managing databases, and researching information required
Experience working in health care environment required
Microsoft Word, Excel, and Outlook experience required
Microsoft Access and One Note knowledge preferred
Experience in FACETS a plus
Telephone customer service experience preferred
Medical terminology experience preferred
CPCS Certification a plus

Temporary Credentialing Specialist Resume Examples & Samples

Prepares Facility/Unit and/or State requirements for each assignment according to contract guidelines
Build strong, trusting and professional relationships with Healthcare Administrators and Vendors nationwide
2-3 years customer service experience, office setting preferred
Effective communication skills and professional demeanor when representing the Company to clients, candidates or other vendors
Well organized and detail orientated. Accuracy in assessment and documentation of credentials is crutial
Beginning knowledge of Human Resources issues related to confidentiality, EEOC, ADA and other related personnel issues preferred
Minimum of one year of successful experience in the healthcare staffing industry

Credentialing Specialist Resume Examples & Samples

Provides exceptional customer service to physicians and physician office staff members as well as internal customers, such as members of other departments. Educates physicians and physician office staff on the credentialing process and maintains ongoing contact with these individuals throughout the process
Obtains timely and accurate primary source verification for all credentialing functions. Completes accurate and timely data entry of all credentialing activity into physician credentialing systems. Interacts with IS Consultant to transition all manual processes to completion of processes within the physician credentialing data system. Maintains medical staff database for all physician and allied health credentialing and privileging activities
Identifies trends and assists in the development of action plans for purpose of performance improvement. Evaluates processes in departmental Policies andamp; Procedures and makes recommendations for changes to Medical Staff Supervisor. Develop and distribute reports as necessary utilizing physician database. Timely completion of all assigned duties
Interacts with and provides support to department chairmen and leadership chairmen in the preparation of meeting calendars and meeting notices. Interacts with department chairman and leadership chairmen in presentation of initial credentialing and reappointment files in preparation for the Credentials Committee. Provides clerical support as needed to the Chief of Staff and Vice Chief of Staff in scheduling ad hoc meetings. Advances department meeting minutes to the appropriate leadership committee
Manages various human resources functions including hiring, work assignments, coaching plans, and performance counseling
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.andnbsp
Assists the Medical Staff Supervisor in providing all credentialing, privileging and meeting support activities for the Orlando Health Medical Staff and its leadership
Ongoing review of processes to improve performance and meet customer needs
Assumes responsibility for professional growth and development
Skills necessary to maintain credentialing, meeting support activities, and reporting abilities relative to physician activity and statistics
Three (3) years experience credentialing/privileging or
One (1) year of credentialing/privileging experience and two (2) years of clinical experience
Associate degree in business, health care, accounting or related field may be substituted for two (2) years of experience
Bachelor degree in health, business or related field may be substituted for three (3) years of experience
Proficiency in Microsoft Word, Excel, Internet and significant proficiency in credentialing data system

Credentialing Specialist Senior Resume Examples & Samples

Assists with hiring of Medical Staff and Provider Services (MSPS) staff
Oversees staff and assists with problem-solving for difficult application or reappointment files
Oversees and prioritizes daily workload/projects of the Credentialing Specialists & , and oversees the timely processing of initial applications and review processes performed by Credentialing Specialists
Identifies necessity for staff training and directs, or participates in, that activity. Serves as mentor for the Credentialing Specialists
Responsible for ensuring that the credentialing of initial applicants for medical staff membership and reappointment is coordinated accurately and timely and complies with defined schedules and TJC requirements
Mails request for medical staff application. Assesses applications for completeness, produce verification letters, determines if further investigation is needed, work with departments and others to make sure all applications s are completed correctly and timely
Conduct primary source verifications
Manage outside requests for practitioner hospital verifications and peer references
Manages the collection and thorough analysis of credentialing information. Investigates issues of concern, generates reports, and presents findings and makes recommendations to the Medical Director, the OMD Director of Operations, the Department Chiefs and the Credentials Committee
Responsible for final review of a practitioner’s credentials file and in collaboration with the Chief Medical Officer makes determination as to whether or not the provider is a candidate for obtaining temporary privileges
Resolves issues regarding provider credentialing and privileging
Execute process for resignation/termination of medical staff
Suspends practice for provider non-compliance with maintaining expirables (i.e. BCLS, med license, any required certifications, DEA, malpractice, etc.). Notifies the appropriate parties of privilege suspensions/ reinstatements due to expiration
Manages delegated credentialing activities (processing files, conducts the preparation for and facilitates annual audits by delegating vendors)
Responsible for tracking and accuracy of data (re: application elements, timeframes for processing, etc.) in Provider databases, and for ensuring process deadlines are met. Communicates appropriate provider information hospital-wide
Lead administrative staff for the Credentials Committee,
Bachelor’s degree in a field related to the position
Direct experience in the credentialing profession
Minimum of three years working experience in a large multi-specialty teaching hospital or medical group practice setting
OR- An approved equivalent combination of education and experience
Experience in organizational process improvement and streamlining systems
CPCS (Certified Provider Credentialing Specialist) or CPMSM certification preferred, but not required
Knowledge of credentialing software

Credentialing Specialist Resume Examples & Samples

Reports to the Director of Clinician Services
Responsible for enrolling new providers with Medicare, Medicaid and other insurance plans
Responsible for maintaining active credentials and rosters with insurance plans
Responsible for managing provider enrollment and individual provider profiles
Responsible for monitoring plan directories to ensure accuracy
Works with Clinician Credentialing Specialist to ensure seamless provider onboarding
Minimum: 3-5 years of experience
Experience with Cactus credentialing software (preferred)
Capable of working independently as required

Licensing & Credentialing Specialist Licensing & Credentialing Specialist Resume Examples & Samples

Research and monitor changes and updates in regulations relating to licensure and general TAC compliance
Responsible for disseminating research to appropriate Vice Presidents of Operations and internal departments as requested
Responsible for preparing, processing and submitting filing packages, including enrollment applications and renewal packages, to various state departments to obtain licenses and certifications
Contact state regulatory agencies (including state sales, tax and business offices, Departments of Health or equivalent, Medicaid and Medicare intermediaries, and Secretary of State offices) to determine regulations required to establish licensure and compliance
Coordinate licensure and compliance of pre and post mergers/acquisitions and start-ups
Coordinate changes in ownership or address for locations and administrators
Communicate with internal departments regarding changes in licensure
Coordinate documentation changes with Reimbursement and Treasury Departments (EFT/EFC)
Maintain active surety bonds and coordinate with broker and state agencies for renewals
Resolve billing issues as it relates to Medicare and Medicaid provider numbers
Assist Location Director, VP Compliance and or Regulatory Affairs Director with information necessary to comply with state audits and/or survey requests
Assist Managed Care and Legal with information necessary for litigation and contracts
Update databases and maintain files for licensure
Track, review, and supplement licensure spreadsheet weekly to determine priorities
Maintain effective and constant communication with the field as well as internal departments (managed care, accounting, accounts payable, legal)
Maintain relationships with state and federal regulators
Conduct consistent follow ups with governmental agencies to facilitate/expediate licensure process and to achieve compliance goals

100

Credentialing Specialist Resume Examples & Samples

Responsible for ensuring providers (doctors, physician assistants, etc.) are credentialed, appointed, and privileged with health plans, hospitals and patient care facilities
Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications
Completes provider credentialing and recredentialing applications
Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
Sets up and maintains provider information in online medical credentialing databases and system
Tracks license and certification expirations for all providers to ensure timely renewals
Provides credentialing and privileging verifications
Position will also include some admin duties such as filing and filling in at the front desk
NC Tracks - NC system for billing Medicaid
Cardinal - Used by managed care organizations
CAQH
NPI - National Provider Identifier
NPPES - System for NPI registration
Familiarity with various insurance providers (BCBS, United Healthcare, etc.)
Multi-tasker
Computer skills - Strong Excel, Word

101

Credentialing Specialist Resume Examples & Samples

Credential and prepare credentialing and re-credentialing files for weekly Medical Director submission and bi-weekly National Credentialing Committee submission
Education: High School diploma or equivalent
Relevant Work Experience: 2 years’ experience in insurance, healthcare or related field required

102

Senior Credentialing Specialist Resume Examples & Samples

Provides technical software support for the application used for provider credentialing in coordination with Information Services
Remains knowledgeable of changes to software and web based credentialing applications including, but not limited to, OneApp Pro, CAQH, PECOS, PROMISe and Cactus
Provides training to new employees and continuing education to existing Credentialing Specialist staff
Serves as project lead on new Physician Practices. Coordinates and delegates assignments to Credentialing Specialist staff
Supports the Manager of Contracting and Credentialing with Productivity and Quality Assurance reporting
Assist with special projects as assigned by Manager
This position will have responsibility for credentialing software data, running reports, mapping application and troubleshooting

103

Credentialing Specialist Resume Examples & Samples

Provides exceptional customer service to physicians and physician office staff members as well as internal customers, such as members of other departments
Educates physicians and physician office staff on the credentialing process and maintains ongoing contact with these individuals throughout the process
Various human resources functions including hiring, work assignments, coaching plans, and performance counseling

104

Credentialing Specialist Resume Examples & Samples

High school graduate or General Equivalency Degree (GED)
2 years recent experience in a hospital or credentialing setting (course work may be substituted)
Proficiency in computer use and database management, including Microsoft Office
Experience in the use of most office equipment (i.e. copier, printer, fax, scanner)
Associate or Bachelor’s degree in a healthcare-associated field
Currently certified with the National Association of Medical Staff Services (NAMSS) as CPMSM or CPSC

105

Credentialing Specialist Resume Examples & Samples

Processes all requests with reference to physician credentialing information including, but not limited to copying documents requested by various documents, addressing issues for physicians regarding lab coats, script pads etc., and creating physician ID, ensuring that physician have all appropriate access
Files all data related to physician credentialing and quality assurance files. Keeps appropriate spreadsheet tracking forms up to date
Maintains physician mailboxes including assigning new mailboxes and cleaning out mailboxes for physicians no longer on staff
Picks up and distributes all physician/Medical Affairs mail. Contacts physicians when documents/packages are delivered from the mail room
Greets and assists all physicians and ancillary staff with issues in a prompt, courteous and professional manner
Assists with department/committee meetings as required by contacting physicians to remind them of department/committee meetings, copying and assembling meeting packets, and preparation of meeting agenda. Attends meetings, as required, taking and preparing minutes
Ensures that all mass mailings are processed within deadline including medical staff dues, reappointment packages and other physician correspondence. Gathers and distributes information regarding the yearly golf outing, physician week celebration and other hospital parties/celebrations
Notifies staff of doctor availability via Meditech MOX
Assist with the process of transitioning the application/re-application process to CD and via the Internet and with the transition of all credentialing functions to the Morrissey MSOW credentialing system
Begins the credentialing process within 48 hours of file receipt ensuring that each file is complete, annotating each file with checklist of missing/incomplete data. Keeps appropriate spreadsheets up to date. Contacts physician regarding deficiencies
Enters appropriate physician data into legacy system and accesses appropriate databases to obtain required credentialing information

106

Credentialing Specialist Resume Examples & Samples

Proficient with MS Office Suite
Auditing experience
Cactus Credentialing System

107

Credentialing Specialist Resume Examples & Samples

A minimum of two (2) years experience in a medical/health care office setting
Experience coordinating meetings and taking minutes
2) Ability to communicate appropriate and effectively with providers, including sensitive and confidential information; 3) Management of multiple deadlines on a weekly and monthly basis. Must be able to prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements
4) Management of initial application process during several high volume times of year
5) Ability to manage work flow in a complex and dynamic environment through the use of technology
6) Detail oriented and highly accurate
7) Demonstrates strong work ethic and maintains high expectation of individual work product

108

Credentialing Specialist Resume Examples & Samples

Medical Credentialer is responsible for all credentialing and recredentialing processes for medical providers in medical group or hospital setting
Ensure providers’ information is up-to-date in database and online systems and that providers are credentialed with specific health plans, hospitals and other patient care facilities and that all federal and state guidelines are met
Medical Credentialer must maintain current copies of all provider documentation including: state licenses, malpractice coverage, certifications, etc
Process provider and medical staff applications and reappointment paperwork
Medical Credentialer is responsible for tracking expiration dates of provider licenses and certifications
Audit system for accurate and up-to-date provider information

109

Provider Enrollment Credentialing Specialist Resume Examples & Samples

Enter and maintain Provider applications, contracts and updates into the system
Enter and maintain all Provider information into credentialing database
Verify potential and existing Provider’s license, liability insurance, BNDD, CDS and DEA certificate
Verify Provider’s education, hospital privileges, Board certification and other criteria as required
Verify accurate banking & billing information
Perform ongoing research to correct data so it does not create duplicate provider, locations, payees, and participation
Maintain credentialing information by reviewing, entering and following up on missing information
Review National Practitioners Data Bank for adverse charges pending or filed against Provider
Track contract applications status
Assure all files have a Welcome, Denial or Term Letter as appropriate
Meet required turnaround times and accuracy rates
Maintain fee schedules by creating, reviewing and auditing provider fees
Keep up to date provider enrollment process and records and track provider participation levels
Facilitate provider related research based on suspended claims, PO returns and other feedback opportunities
Participation in credentialing committee as necessary
Update the system and the credentialing database to reflect approvals, denials and/ or terminations
Available overtime hours
Assist with other duties as assigned
Previous experience working with files or the collection and coordination of data preferred
Proficient in the use Excel required
Experience with general computer software (Word, Outlook required)
Ability to learn new software programs quickly
Good basic math skills
Professional and effective interaction skills with co-workers, clients, Providers, vendors
Proven ability to work well individually and as a team member
Ability to adapt to constantly changing environment
High School diploma or equivalent, Associate’s degree preferred
1-2 years of experience in business environment

110

Credentialing Specialist Resume Examples & Samples

Essential functions occur simultaneously, therefore, the employee must be able to appropriately handle each essential function, prioritize them, and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment. Requires the ability to learn and apply TAHP policies consistently and seek out guidance when necessary
Responsible for maintaining and processing physician and provider credentialing information for new and established health plan practitioners in accordance with THP's policies and procedures, state laws and regulatory agencies, including but not limited to
Prepare files that may not Meet Credentialing Criteria for review by the Medical Directors and/or Senior Credentialing Specialist and/or Supervisor and presentation to the Quality of Care Committee (QOCC), including report of adverse information
On a daily basis, process all delegated practitioners under the terms and conditions of the entities' delegated agreement, including files credentialed through a Certified Verification Organization (CVO)
Participate in task forces and/or other meetings as assigned and execute other responsibilities as assigned
COMPLEXITY
PERSONAL CONTACTS
PHYSICAL WORK ENVIRONMENT

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Credentialing Specialist Resume Examples & Samples

Word processing skills
Certification through the National Association of Medical Staff Services (NAMSS)
Experience in a Medical Staff office or comparable health care setting

112

Credentialing Specialist Resume Examples & Samples

Accountable for processing and verification of documents related to medical staff applications, reappointment of members (every 2 years), and ongoing maintenance of the credentials files for current licensure, certification, liability coverage, controlled substance and drug enforcement certification. Facilitates process as stated above with appropriate primary source verification
Responsible for timely and thorough completion of credentialing verification process, according to the Medical Staff Bylaws, Joint Commission, and other regulatory bodies
Assists the Credentialing Coordinator in maintaining and updating the credentialing database as needed
Maintains confidentiality of both verbal and written communication regarding credential files and other documentation related to medical peer review, quality improvement and medico-legal issues
Responsible for executing provider mailings as needed
Provides administrative support for Credentialing Coordinator
Working knowledge of computers and proficiency in Microsoft Office
Must possess effective verbal and written communication skills

113

Credentialing Specialist Resume Examples & Samples

Work independently to ensure all payer contacts for home health, hospice, and private duty agencies are properly credentialed in new and existing payer contracts
Initiate and develop best practice for credentialing process for most efficient credentialing processing
Work with MAC to maintain payer contracts and contract summaries
Communicate credentialing and contract needs to agency leadership team
Update all payer contracts in contract payer summaries in a timely manor
Work directly with MAC to ensure training and support to agency leadership team
Support PACC Director to Identify new network opportunities by tracking current participation alternative payment models and formulate recommendations to PACC and MC resources
Exercise independent judgment and discretion in the research, development, and maintenance of alternative care and payment model systems, tools, and processes taking into considering quality, patient experience and financial impact
Support PACC Director and MC Resource to design innovative education presentations for home health agencies, potential network partners, current network partners, and the healthcare community
Analyze PACC performance outcome metrics utilizing the PACC Tracking tool to identify areas requiring performance improvement plans. Notify facility IDT and continuum partners regarding outcome metrics falling below the quality performance threshold
Assist PACC Director in coordinating with agency IDT to identify PACC performance outcome metric goals and thresholds for requiring performance improvement plans
Create, track, maintain and report on data for outcome metrics in alternative payment models participation, managed care contracts, and on company, cluster, and agency outcomes for Star and Home Health Compare
Provide guidance and support for innovative payment model agreements, including specific performance outcome metrics, provider gain sharing, physician alignment and value based purchasing/pay for performance models
Maintain current knowledge of alternative payment models (e.g., episodic payments: ie., bundle payments for care improvement initiative, accountable-care organizations, managed care bundling and clinically integrated networks, etc.) and health care policy as it relates to continuum provider services, regulatory compliance and alternative payment models
Attend quarterly PACC Resource meeting, weekly PACC WebEx and partner with PACC Resource team where needed to develop continuum best practice tools and processes
Qualified candidate must have a bachelor's degree in a healthcare related field or 3 + years in a similar position
Basic understanding of the post-acute care continuum, health care policy and alternative payment models (BPCI, ACO, Managed Care)
Strong working knowledge of excel to develop and maintain tracking tools both financial and outcome based
Must possess skills needed to collaborate and strategize with all continuum partners to build seamless quality transitional care processes across multiple settings within the continuum
Basic knowledge base of the evolving changes within the healthcare industry. Including Accountable Care Organizations, Bundled Payments for Care Improvement Initiative, transitional care models and consortiums, Long-Term Care Reform Proposal, IMPACT Act, current and future regulatory compliance policy, Comprehensive Care for Joint Replacement Initiative, Hospitals Improvement for Payment Act, Bundling and Coordinating Post-Acute Care Act, MedPAC Post-Acute Payment Report
Must understand how post-acute care continuum performance has a direct impact upon agency, cluster, company and organizational strategic growth objectives
Must be highly professional in demeanor
Able to think outside the box
Strong analytical and financial skills, and communication skills
Must be a team player, critical and creative thinker, and able to build relationships across the team in order to push PACC initiatives forward

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Credentialing Specialist Resume Examples & Samples

Collect all relevant information from the provider, provider’s insurers, National Practitioner Data Bank (NPDB), state licensing departments, educational institutions, board certifications and OIG sanctions list and other sources as appropriate
Identify needed or missing or incomplete information and follows up in obtaining such information
Meet all credentialing and re-credentialing timelines and schedules, ensuring that credentialing and re-credentialing of providers occurs on a timely basis in accordance with industry and company standards

115

Credentialing Specialist Resume Examples & Samples

Experience in credentialing and/or process management and operations experience
Excellent verbal and written communication skills to effectively interact with physicians and allied health professionals, their office credentialing representatives, and hospital personnel
Excellent computer skills, including Excel
Highly organized to meet deadlines and work independently in a fast paced, multi-functional environment where tasks and assignments are constantly changing

116

Credentialing Specialist Resume Examples & Samples

Completes administrative duties, such as ensuring state medical licenses are up-to-date and checking the status of new license applications
1 year previous experience in credentialing or related health care field preferred
Organizational skills, detailed oriented, working knowledge of Microsoft Office, professional written/verbal communication skills

117

Credentialing Specialist Correspondence Resume Examples & Samples

Organization – proactively prioritizes needs and effectively manages resources. Ability to show attention to detail
Communication – communicates clearly and concisely. Must have excellent interpersonal and written communication skills. This includes spelling and grammar skills and basic mathematical calculations
Policies & Procedures – articulates knowledge and understanding of organizational policies, procedures, and systems
Minimum one-year experience preferred in healthcare credentialing (i.e., healthcare facility, managed care setting, credentials verification organization, or Medical Staff Office)

118

Credentialing Specialist Resume Examples & Samples

Handles the billing, collection, and deposit of medical staff dues
Schedules, coordinates and attends all assigned department and committee meetings, conferences and special events in support of medical staff credentialing activities
Communicates with both internal and external customers concerning the credentialing activities and operation of the department, including verification requests regarding hospital privileges, past residencies, and fellowships
Ensures data integrity. Maintains adequate documentation for analysis, data retrieval, and troubleshooting of systems and databases
Minimum Qualification: One year of experience in an administrative support role within a healthcare environment

119

Credentialing Specialist Resume Examples & Samples

Career guides, information and tools to help you successfully position yourself throughout every stage of your career
Group-rate insurance options available immediately upon hire*
Important information: This position is recruited for by a remote Kelly office, not your local Kelly branch. Please submit your resume to be considered for this position by pressing the “SUBMIT RESUME” button below. Please email Courtney Keller at kelleco@kellyservices.com for any additional questions about the job posting

120

Credentialing Specialist Resume Examples & Samples

Related and relevant experience or a demonstrated ability to perform the duties of the position may be considered in lieu of the academic requirements
Medical terminology recommended
Knowledge of ECHO, Word, Excel, and Access preferred
Must be organized and be able to work quickly, independently, and with little supervision
Two years experience in healthcare setting

121

Credentialing Specialist Resume Examples & Samples

Effective ability to work both independently and within a team environment
Prior experience supporting hardware and software installations
Ability to prioritize and complete projects within deadlines
Self starter, independent thinker, and worker
College degree or equivalent work experience
Communicates via telephone with physician offices to update / modify physician credentials within HCHB system
Coordinates user and support issues among corporate site and remote office locations to ensure timely distribution of knowledge and positive impact on user satisfaction and productivity
May act as product liaison for major products, working with other corporate departments and third-party developers to solve technical issues as needed
Acquires and maintains knowledge of relevant product offerings, current support policies, and methods of support delivery, in order to provide technically accurate solutions to users

122

Credentialing Specialist Resume Examples & Samples

Credentials HFNY Vendors and Facilities as well as Level III Providers while ensuring all credentialing documents are complete and accurate in accordance with established credentialing policies and procedures
Completes data input of vendors in Excel, creates spreadsheets and runs reports as needed
Creates mail merge documents using MS Word; mails acceptance letters and other documents
Effectively communicates, verbally and in writing, to internal departments and external partners using Outlook and other resources
Conducts abbreviated credentialing reviews for Delegated Providers (Level I & II), and advises the Manager of Credentialing of results. If issues are discovered, the Project Specialist must provide necessary details to the Manager of Credentialing for presentation to the credentialing committee
Maintains CACTUS database of HFNY Providers by updating the system to ensure all credentialed Providers are captured
Assists the Manager of Credentialing in running ad-hoc reports as required by internal and external customers, and generates reports for the credentialing and re-credentialing of Delegated (Level I & II) and Level III Providers
Work experience credentialing in a health care environment
Work experience creating spreadsheets, performing mail merges
Work experience with Microsoft Access and Visual CACTUS

123

Credentialing Specialist Resume Examples & Samples

Use pertinent data and facts to identify and solve a range of problems within area of expertise
Investigate non - standard requests and problems, with some assistance from others
Work exclusively within a specific knowledge area
Provide explanations and information to others on topics within area of expertise
Design and complete data analysis projects for department customers including defining informational
Needs, appropriate methodologies and report formats. Provide written reports with accompanying documentation of findings
Conducts audits of the credentialing database, confirming accurate input of provider data, including auditing other staff data entry and verifying accuracy of modifications made to the database
Monitor security of data within the Credentialing Database with individuals to whom data or system access may be given; report infractions to the Credentialing Supervisor
Act as project leader and assist in the development of provider data reporting, as requested
Collaborate with Information Technology to review approved software installs, upgrades, incremental backups and restorations; assist in the development of configuration documentation and updates as necessary
Maintain appropriate logs of database - related problems and modifications; monitor database performance and space; investigate and resolve all departmental problems, questions and concerns and make modifications, as necessary. Report all systemic database issues to Supervisor
Disseminate new / modified professional information to HMOs and to internal departments through the Information System Change Control Process
Process credentialing / re - credentialing applications accurately and promptly in accordance with internal medical group policies and procedures and NCQA standards. Coordinate the credentialing and re - credentialing processes with the Quality Improvement Department and other internal departments, as necessary
Prepare materials and files necessary to comply with external audits by health plans or governmental agencies
Undergraduate degree or equivalent healthcare experience
3+ years of experience with credentialing / re-credentialing and / or privileging in the healthcare industry
2+ years of experience with healthcare accreditation and regulatory standards including NCQA requirements
Intermediate level of proficiency with MS Excel and Access
Intermediate level of proficiency in performing research
2+ years’ experience in credentialing, preferably in a managed care setting
Advanced Access and Excel knowledge
Knowledge of Practice Management Software and eVIPs Software System

124

Credentialing Specialist Unc Omss Resume Examples & Samples

Coordinates the administration and scheduling of a variety of professional meetings, seminars, or conferences. Coordinates the planning and logistical arrangements for special events. Maintains detailed calendars and records and confirms logistics associated with events
Prepares a variety of office documents, records, reports, charts and graphs. Determines some format, content and presentation. Gathers, analyzes and compiles information into report format
Provides leadership and guidance to co-workers
Responds to inquiries with written explanation by interpreting established policies and procedures. Coordinates mail screening and distribution

125

Credentialing Specialist Resume Examples & Samples

Establishes, maintains, and updates files, databases, records, and/or other documents. Maintains Centralized Credentialing Policy and Procedure manual as agree upon by entities
Reviews and screens initial and reappointment medical staff credentialing applications for completeness, accuracy, and compliance with Centralized Credentialing Policies and Procedures
Facilitates monthly User’s Group meetings
Ensures confidentiality of data as required by legal and organizational standards
Ensures quarterly billing is distributed in a timely fashion

126

Credentialing Specialist Resume Examples & Samples

High School diploma or GED required; Associates Degree preferred
Two (2) years of healthcare operations experience required
Credentialing experience preferred
Demonstrated experience in Windows and Microsoft Word. Knowledge of HealthRules and Visual Cactus preferred
Excellent organizational and time management skills with ability to prioritize work according to established deadlines
Must be able to manage multiple projects
Ability to work independently owning a process from start to finish while under strict deadlines and decision making skills commensurate with position responsibilities
Excellent written and verbal communication skills; demonstrated ability to communicate with physicians and health care providers; excellent customer service skills

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Credentialing Specialist Resume Examples & Samples

Credentialing Specialist Resume Examples & Samples

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Credentialing Specialist Resume Examples & Samples

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Credentialing Specialist Resume Examples & Samples

Credentialing Specialist Resume Examples & Samples

Credentialing Specialist Resume Examples & Samples

Credentialing Specialist Resume Examples & Samples

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