Job Description

Role : Credentialing Specialist Job Description

Department : HR

Direct Report : Director of HR

Summary: Responsible for all aspects of the credentialing, re credentialing, and privileging processes for all medical providers who provide patient care as clients of Exceed Healthcare. Responsible for ensuring providers 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.

Job Duties:

As a Credentialing Specialist for Exceed Healthcare LLC, Your job duties include, but are not limited to, the following:

Hospital/Provider Credentialing

• Compiles and maintains current and accurate data for all providers.
• Complete provider credentialing and re credentialing applications; monitors applications and follows-up as needed.
• Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
• Maintain knowledge of current health plan and agency requirements for credentialing providers.
• Set up and maintain provider information in online credentialing databases and systems.
• Tracks license and certificate expirations for all providers to ensure timely renewals.
• Ensures practice addresses are current with health plans, agencies and other entities.
• Processes applications for appointment and reappointment of privileges for providers who are clients of Exceed Healthcare.
• Tracks license, DEA, and professional liability expirations for appointed Exceed Healthcare providers.
• Maintains Exceed Healthcare client appointment files, and information in credentialing database.
• Set up and maintain provider information via CAQH.
• Accessing PHI/EPHI. Credentialing Coordinators will only access this in direct relation to patient care.
• Manage the completion and submission of initial provider malpractice insurance applications.

Payer Credentialing

• Performs follow-up with insurance payers via phone, email or website to resolve payer credentialing issues.
• Works closely with external payer credentialing vendors on notification of a provider's start, welcome packets, provider documentation and ensuring the provider is in all systems.
• Manage the completion and submission of provider enrollment applications.
• Perform tracking and 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 prerequisites, forms required, form completion requirements, supporting documentation (DEA, CV, etc.) and regulations.
• Maintain documentation and reporting regarding provider enrollments in process.
• 7. Retain records related to completed payer credentialing applications.
• Update insurance programs with location change information within 90 days of change.
• Ensure accounts, PTAN, and other identifying numbers remain active.
• Diligent follow up with insurance companies throughout the application process.

Additional Responsibilities:

1. Maintain confidentiality of provider information

2. Provides credentialing and privileging verifications

3. Performs other duties and special projects as assigned.

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