Credentialing Specialist

Primary Responsibilities:

1. Credentialing and Recredentialing: Manage the process of initial credentialing and recredentialing for healthcare providers. This includes verifying education, training, residency, licenses, and board certifications.

2. Database Management: Maintain accurate and uptodate records of healthcare providers' credentials using healthcare information systems like Athena Health. Ensure that all data is securely stored and easily accessible for verification and compliance purposes.

3. Insurance Processing: Liaise with insurance companies to ensure that healthcare providers are properly registered and approved to offer services covered by insurance. This involves submitting detailed information and documentation to insurance providers and addressing any issues or discrepancies that may arise.

4. Regulatory Compliance: Ensure that all credentialing activities comply with federal and state regulations, as well as standards set by healthcare accreditation organizations. Stay updated on changes in regulations and accreditation standards.

5. Provider Support: Serve as the primary point of contact for healthcare providers throughout the credentialing process. Provide guidance and assistance to providers to ensure that they complete all necessary steps efficiently and correctly.

6. Collaboration with Healthcare Facilities: Work closely with hospitals, clinics, and other healthcare facilities to ensure that their staff meets all credentialing requirements. Coordinate with facility administrators and human resources departments as needed.

Skills and Qualifications:

Expertise in AthenaHealth: Proficient in using Athena Health's credentialing and provider management modules. Familiarity with navigating its interface and utilizing its features to manage provider data and credentials.

Insurance Knowledge: In depth understanding of various insurance processes, including billing codes, insurance verification, and claims processing. Ability to work with multiple insurance providers and understand their credentialing requirements.

Attention to Detail: Excellent organizational skills and a keen eye for detail, ensuring that all aspects of provider credentialing are accurately managed.

Communication Skills: Strong written and verbal communication skills for interacting with healthcare providers, insurance representatives, and facility administrators.

ProblemSolving: Ability to identify and resolve issues that may arise during the credentialing process, including discrepancies in documentation or delays in insurance processing.

Education and Experience:

• A degree in health administration, business administration, or a related field is often preferred.
• Previous experience in healthcare credentialing, provider relations, or a similar role is highly valuable.
• Experience with hospital credentialing applications.
• Knowledge and experience with PECOS for Medicare applications and recredentialing.
• Certification in provider credentialing (e.g., Certified Provider Credentialing Specialist (CPCS)) is a plus.

Working Conditions:

• This role is virtual, allowing for remote work from a home office.
• It may require flexibility in hours to accommodate different time zones and deadlines.