[Hiring] Credentialing and Licensing Specialist @BETTERHEALTH A PLANNED PARENTHOOD PARTNERSHIP

Role Description

The Credentialing and Licensing Specialist plays a vital role in healthcare operations by verifying that medical professionals meet all required licensure, certification, and regulatory standards often under tight deadlines and strict compliance mandates. Responsible for oversight of all aspects of the credentialing, recredentialing, and health plan or hospital privileging processes for providers, such as physicians, and qualified healthcare professionals (QHPs) who utilize BetterHealth for credentialing services. This includes ensuring physicians are privileged when required by individual health plans. Maintains and monitors all facility credentialing for locations such as ambulatory surgical centers, pharmacies, and laboratories.

Essential Functions

• Performs all credentialing and licensing duties with superior expertise, consistency, and quality.
• Demonstrates effective customer service and communication skills to enhance relations with internal team members and affiliate client relations.
• Displays professionalism and encourages a positive, team-oriented work environment.
• Demonstrates ability to be a self-starter and work with minimal direction.
• Compile and maintain current and accurate electronic data for all providers.
• Complete and maintain the Affiliate Risk Management Services (ARMS) required credentialing and recredentialing of all organizations who utilize BetterHealth for credentialing services.
• Apply for ARMS malpractice coverage for new providers (APRNs, PAs and physicians), including offsite emergency coverage for physicians. Annually review the malpractice coverage for all providers for PPGC and/or client Affiliate.
• Maintain documentation within all third-party software systems (i.e., Modio, CredentialSmart or other systems) for primary source verification.
• Create, update, and maintain CAQH Proview database accounts for all physicians and QHPs.
• Acquire accounts for new providers not previously registered with CAQH.
• Obtain, update, and maintain the National Plan and Provider Enumeration System (NPPES) / Provider Enrollment, Chain and Ownership System (PECOS) accounts for all APRNs, PAs and physicians.
• Maintain electronic copies of current state licenses, Board certification, DEA registration, client Affiliate state required certificates, malpractice coverage and any other required credentialing documents for all providers.
• Obtain electronic signatures for new APRNs, PAs and physicians as needed.
• Complete, monitor and follow-up as needed, provider credentialing and recredentialing applications with all commercial, Medicaid, Medicare, and Medicaid managed care payers.
• Provide all payers with demographic updates when providers are added or terminated.
• Maintain electronic folders of signed physician contracts including archived contracts.
• Manage and maintain confidentiality of provider information, including corporate related information needed for federal/state agencies.
• Assist with revenue cycle processes that may include, but are not limited to filing appeals, billing, follow-up, insurance benefit verification, payment posting and self-pay collections and customer service.
• Other duties as assigned.

Supervisory Responsibility

This position has no supervisory responsibility.

Competencies

• Business Acumen, Strategic Thinking, Problem Solving
• Customer Service and Interpersonal Skills, Oral, and Written Communications
• Ethics, Diversity, Initiative, Teamwork, Leadership
• Computer and Technical Skills
• Quality, Safety & Security
• Analytical, Business Acumen
• Decision Making, Innovation, Judgment
• Problem Solving, Quantity, Technical Skills

Qualifications

• High school diploma or GED
• Minimum of three years direct experience with credentialing providers in a medical practice, with the accompanying knowledge and understanding of the credentialing process with health insurance plans and use of CAQH Proview.

Skills

Required

• Ability to handle highly confidential and sensitive matters and documents.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Knowledge of business practices and protocols.
• Ability to handle multiple priorities and projects.
• Ability to demonstrate initiative and work with minimal direction.
• Ability to perform duties in a manner that exhibits commitment to providing quality service and continuous improvement.
• Experience working with state Medicaid plans.
• Possesses excellent time management and organizational skills.
• Demonstrates adaptability and flexibility with respect to changing end-user business needs.
• Demonstrates a willingness to learn new software and systems.
• Conveys information clearly and concisely with project leadership and subject matter experts.
• Conveys the ability to gain trust and establish effective relationships with peers and leadership.
• Seeks, logically examines, and interprets information from various sources to determine a problem’s cause and develops a course of action to resolve the problem and to prevent its recurrence.
• Has a demonstrated understanding of the role that racial inequity plays in our society and its impact on healthcare systems and institutions.

Preferred

• Possesses prior end-to-end credentialing experience.

Physical and Environmental Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, talk, and listen. Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus.

• Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time).
• And/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• Must be able to travel throughout and between facilities.
• Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.
• There is no occupational risk for exposure to communicable diseases.

Duties and responsibilities may be added, deleted, or changed at any time at management's discretion, formally or informally, either verbally or in writing.