The Delegated Credentialing Specialist II is responsible for ensuring that all employed Memorial physicians and providers are credentialed with the appropriate delegated insurance plans, governmental agencies and any other participating insurance plans. The Specialist II oversees the preparation and processing of information and monitors compliance with regulatory and accrediting bodies as well as delegated rules and regulations. The Specialist II maintains accurate and up to date data within the relevant databases.
Responsibilities
- Responsible for compiling and completing physician and provider credentialing forms for appropriate payor delegations
- Initiates the verification and documentation processes for submitted applications
- Coordinates completion of physician and provider participating applications and credentialing files
- Collaborates with insurance plan providers and representatives to obtain and complete specific payer credentialing forms and applications
- Responsible for preparing and providing information to various departments and external entities
- Communicates with appropriate billing staff regarding the status of a provider's enrollment with individual payers
- Facilitates provider-related research based on suspended claims, denial issues related to the enrollment process and other feedback opportunities
- Provides requested information to authorized agencies for audits and reviews
- Ensures compliance with delegation monitoring and oversight requirements for credentialing functions
- Collaborates with the various departments to conduct the timely credentialing delegation audits
- Performs the post-audit results meetings with insurance representatives and contributes to the resolution of any audit findings
- Attends provider onboarding to obtain additional information/signatures from providers
- Maintains and updates physicians and provider information in the applicable databases
- Maintains credentialing database and provider billing number tracking sheet
- Monitors and tracks license and certification expirations and renewals and provider information
- Maintains physician and provider directory information for departments and hospital
- Performs tracking and follow-up to ensure provider numbers are linked to appropriate entity and location
Qualifications
Education:
- Required - Associates degree in Business or healthcare related field; Experience may be accepted in lieu of degree requirement
- Preferred - Bachelor's Degree in Business or Healthcare related field
Certification:
- Required - Certified Provider Credentialing Specialist (CPCS) from the National Association of Medical Staff Services
Experience:
- 2 years Directly related credentialing experience
Skills:
- Strong verbal and written communication skills
- Data entry with minimal errors
- Database management
- Seeking solutions using appropriate methodologies
