[Hiring] Credentialing Specialist @Curana Health, Inc.

Role Description

Under general supervision, the Credentialing Specialist is responsible for all functions relating to the credentialing and recredentialing of practitioner applicants. Thus, ensuring the plan provider network consists of practitioners that meet the regulatory criteria to minimize liability to the company and to maximize safety for members.

Essential Duties & Responsibilities

• Data entry, data collection, verification of credentials from primary source, and analysis of information collected according to Curana Health policies and procedures.
• Maintain confidentiality regarding legal matters, privacy issues, information technology, and data integrity.
• Perform detailed and thorough review of applications for completeness.
• Conduct, maintain, and analyze Primary Source Verifications (PSV) as outlined in the organization policies while meeting production goals.
• Recognize potential discrepancies and adverse information, and independently investigate and validate information from applications, primary source verifications, or other sources.
• Communicate with health care practitioners to clarify questions and request any missing information.
• Conduct follow-up on application requests and outstanding PSVs, following department guidelines and production goals.
• Maintain credentialing software database by ensuring that data entered is complete and accurate.
• Communicate with internal and external customers in a clear, concise manner to obtain or provide necessary information.
• Compile, evaluate, and present the practitioner-specific data collected for review by the Credentials Committee.
• Create and send formal approval, requests for information, and termination notices to practitioners based on Credentials Committee decisions.
• Request recredentialing applications from practitioners and organizational providers.
• Collaborate with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
• Conduct ongoing monitoring of provider expirables such as license, DEA, and malpractice insurance.
• Review and process assigned federal/state and license sanctions and exclusions reports to determine if practitioners have sanctions/exclusions.
• Review and process assigned NPDB Continuous Query reports and take appropriate action when new reports are found.
• Assist with Delegation Oversight audit reviews, tracking, and reporting.

Qualifications

• High school diploma required; Associate degree preferred.
• 1-4 years of hospital or insurance plan credentialing experience.
• Working knowledge of Joint Commission, NCQA, URAC, HFAP standards.
• Certified Provider Credentialing Specialist (CPCS) preferred.