The primary purpose of this position is to facilitate provider onboarding by assisting with hospital privilege acquisition and enrolling credentialed providers with the appropriate insurance plans and payers. The Specialist ensures a smooth and timely credentialing process to support provider integration.
Qualifications
Education:
Graduation from high school or possession of a high school equivalency diploma
Associate’s degree, preferred
Experience:
1 year of medical office experience of which included healthcare credentialing functions
License/Registration/Certification:
Certified Provider Credentials Specialist (CPCS), Certified Professional Medical Services Management (CPMSM) or Certified Provider Enrollment Specialist (CPES), preferred but not required
Specialized Knowledge/Skills:
- Knowledge of credentialing requirements, regulations, applicable standards.
- Working knowledge of Microsoft Office
- Familiarity with electronic credentialing software
Essential Functions
- Complete and process provider credentialing and re-credentialing applications accurately and timely.
- Monitor application statuses and proactively follow up to meet deadlines, ensuring patient responsibilities and contract requirements are fulfilled.
- Compile and maintain up-to-date copies of provider credentials, including state licenses, registrations, DEA certificates, malpractice coverage, and other required documents.
- Maintain comprehensive credential files for each provider, ensuring all information is current and accurate.
- Track license and certification expiration dates to facilitate timely renewals.
- Serve as a liaison between the GSS Credentialing Department, area hospitals, and payers to facilitate smooth credentialing processes.
- Participate in the development, review, and revision of credentialing policies, procedures, quality assurance, and professional standards.
- Contribute to performance improvement initiatives aimed at enhancing the quality of credentialing services.
- Act as the primary contact for provider enrollment across all supported clinics and services.
- Complete and track enrollment applications for Medicare, Medicaid, commercial insurance plans, and CAQH.
- Monitor and ensure timely completion of all re-enrollment and revalidation activities.