Job Description

2 years exp. in Excel spreadsheet, JIRA

3 years physician credentialing experience or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.

ESSENTIAL FUNCTIONS:

40% Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the CareFirst networks. Once verified, accepted and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.

30% Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, contractual status and provider file updates. Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved. Professional etiquette, communications and sound decision making is required.

15% Maintains the provider file, the Provider Information Control (PICS) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities.

10% Responsible for identifying, analyzing and resolving immediate and existing provider file issues. Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered into the provider file database, ensuring a successful integration with the other corporate systems.

5% Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable

accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma

Experience: 3 years physician credentialing experience or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.

Preferred Qualifications

Bachelor's Degree in Business, Healthcare Administration or related field

Knowledge, Skills and Abilities (KSAs)

Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables., Proficient

Excellent verbal and written communication and interpersonal skills. Ability to develop and maintain effective relationships with peers, physicians, and medical staff to create confidence, respect and dependability., Proficient

Knowledge of medical terminology, Proficient

Demonstrated proficiency utilizing reference materials and ability to follow Standard Operating procedures to reduce risk and ensure provider data accuracy and overall quality., Proficient

Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes and interpret reasoning for performing verification and/or appropriate actions., Proficient

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Licenses/Certifications

Certified Provider Credentialing Specialist (CPCS) Pref

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