Credentialing Specialist

About the role

You will confirm that affiliated physicians, independent practitioners and allied providers meet the standards needed to serve health plan members, following internal policy, state law and regulatory rules such as NCQA. Practitioners are rechecked at least every three years, or sooner when required.

What you will do

• Keep provider credentialing records current for new and existing practitioners, in line with policy, law and regulator expectations
• Enter initial and renewal applications accurately and promptly into the Cactus credentialing system
• Confirm licences, board certification and similar details through the appropriate sources
• Review and flag adverse findings from the National Practitioner Data Bank and from state or federal sanctions
• Chase missing or expired documents needed to complete credentialing files
• Prepare files for daily medical director review and for the quality of care committee, and advise on questions about certification

What they look for

• Ability to juggle several essential tasks at once, set priorities and ask for help when needed
• Consistent application of organisational policy and sound judgement, seeking guidance when appropriate
• Working knowledge of provider contract information sufficient to judge participation eligibility
• Familiarity with credentialing rules from regulators and state law
• Care in handling sensitive provider information and reporting adverse findings