Credentialing and Contracting Specialist

: JOB SUMMARY The primary responsibilities are to perform administrative tasks pertaining to credentialing new providers and maintaining credentials for current providers at Sunshine Pediatrics, along with reviewing current rates and payments from insurance payers.

• Completes practitioners' applications/reapplications
• Responds to requests from insurance companies for information/documentation
• Follows up with insurance companies and hospitals regarding status of practitioner's applications
• Notifies insurance carriers when a practitioner leaves the practice
• Notifies insurance carriers when a new practitioner joins the practice
• Tracks information to promote speed of processing
• Processes change of addresses for each practitioner/practice location
• Manages renewals of medical licenses, DEA's, occupational licenses for all practitioners
• Maintains the NPI (National Provider Identifier) and CAQH (Council for Affordable Quality Healthcare) data bases
• Maintains a current electronic insurance grid identifying the credentialing status of all practitioners for contracted payers and government agencies
• Maintains a resource file on each practitioner
• Maintains a current chart overview of the payment rates received from insurance payors and proactively reviews payments on a daily basis
• Identifies potential changes in payments from payors and notifies insurance to correct reimbursement
• Scans/Faxes and Medical Records as needed.

JOB REQUIREMENTS

• High school graduate or GED equivalent
• Minimum 1 year experience in credentialing
• Strong aptitude for customer service and telephone etiquette
• Organized, detail-oriented, and diligent work ethic
• Proficient in Word ,Excel, Adobe (PDF), Outlook
• Knowledge of CAQH and I&A, PECOS/CMS applications
• Credentialing Specialist Certification (CPCS) Preferred

KNOWLEDGE, SKILLS, AND ABILITIES

• Working knowledge of CAQH (Council for Affordable Quality Healthcare) and I&A, PECOS/CMS applications
• Excellent written, oral communication, analytical skills, and customer relations
• Ability to organize, prioritize, and effectively work on multiple projects at one time
• Ability to read and communicate effectively in English. Additional languages preferred
• Ability to communicate in a professional manner, able to counsel/teach customers, train co-workers, and positively contribute to marketing/public relations
• Ability to respond to common inquiries or complaints from patients, regulatory agencies, or members of the medical and business community
• Must be able to work in an environment where production goals are set to be achieved