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Credentialing Specialist

Company: SOLIS Health Plans
Location: Miami
Posted on: May 27, 2023

Job Description:

Responsible for credentialing and re-credentialing activities of health care providers and facilities to ensure compliance with appropriate accrediting and regulatory agencies. Responsible for maintaining data integrity of credentialing database

  • Screening practitioner and facility applications and supporting documentation to ensure compliance with minimum credentialing criteria

  • Process practitioner and facility initial and re-credentialing activities in compliance with NCQA, state, an/or federal regulations and requirements, as applicable

  • Maintain excellent communications and strictly adheres to department processes between credentialing, provider relations and contracting

  • Maintains Credentialing database to ensure data accuracy

  • Ensure provider credentialing and re-credentialing is conducted in accordance with organizational policies and applicable government and regulatory agency standards and guidelines.

  • Maintains credentialing reports

  • Prepares agenda, documents, and minutes for the Credentialing Committee

  • Ability to perform monthly monitoring of NPBD and oversee sanctions process including but not limited to streamline verify

  • Effectively improve operational processes to achieve maximum efficiency.

  • Assists in the review of Credentialing policies and procedures.

  • Maintains confidentiality of all information in compliance with State and Federal law.

  • Communicates effectively with other professionals in order to achieve positive customer outcomes.

  • Promotes and contributes to a positive, problem-solving environment.

  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.

  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations.

  • Participates in meetings, training and in-service education, as required.

  • Performs other duties as assigned.

    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    • At least one (1) year experience with credentialing in a health plan setting with Medicare experience preferred but not required

    • Provider network management or provider relations experience a plus

    • Knowledgeable of CMS/Medicare and NCQA credentialing requirements

    • Excellent customer service skills required

    • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office

    • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization

    • Ability to work effectively independently and in a team environment

    • Ability to read, analyze, and interpret technical procedures or governmental regulations

    • Ability to write reports, business correspondence, and procedure manuals

    • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public

    • Ability to define problems, collect data, establish facts, and draw valid conclusions

    • Strong decision-making, analytical skills

    • Must be self-motivated, organized and have excellent prioritization skills

    • Must be able to work well under stressful conditions

    • Must be able to work in a fast paced environment

    • Fluency in Spanish and English required

      The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

      • The noise level in the work environment is usually moderate.

      • Fast pace office environment.

      • Highly regulated environment.

      • Interacts with members, vendors, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

        This work may require the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours.
        Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays as needed.
        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.
        The employee must be able to frequently lift up to 15 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required to this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

        • Duties accomplished at the end of the day/month

        • Attendance/Punctuality

        • Compliance with Company Regulations

        • Safety and Security

        • Accuracy Rate

          This Job Description may be modified at any time at the discretion of the employer as business operation may deem necessary. This does not constitute an employment agreement and may not include all duties.
          The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with demonstrated ability to juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.
          Solis Health Plans provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
          This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Keywords: SOLIS Health Plans, Miami , Credentialing Specialist, Other , Miami, Florida

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