Job Description

Credentialing Specialist II

This is an experienced position that performs all provider credentialing verifications and credentialing support tasks. Additionally, this position is responsible for the execution of contracting documents for individual and group providers.

Credentialing Activities:

• Completion of primary source verifications based on the requirements of each provider professional level. Verifications include: license; licensing board, Federal, State and Professional sanctions, general risk/liability assessment, malpractice coverage, malpractice history, education and experience, professional and board certifications. Adheres to Magellan, client, accrediting and regulatory credentialing timelines and standards. Consistently meets or exceeds productivity and auditing standards.
• Assessment and referral of all credentialing materials, as necessary, to quality and/or legal review, to include tracking of process.
• Completion and review of all provider credentialing materials in preparation for PPRC review. Communication and coordination with the PPRC review process.
• Perform review and analysis of incoming documents to determine completeness of applications and contractual documents. Contact providers telephonically and/or via correspondence to inform providers of missing documents/elements. Obtain missing documents and forward complete applications and contractual documents to processing units.

Contracting Activities: (Primarily individual contracts only)

• Communicate via telephone, e-mail, and US mail with Field Network staff and Provider community regarding contract documentation questions, issues, and or concerns.
• Reviews contractual documents for completeness.
• Determine appropriate network participation status; investigate accuracy of affiliations and contract/rate documents. Communicate with other Network staff to ensure accuracy of rates and reimbursement to providers.
• Execute appropriate contractual document; update affiliations in the provider database to reflect participation status, request correspondence to providers to communicate contract status and effective dates; create website logins for providers.

Contracting Activities: (Primarily Group contracts only)

• Communicate via telephone, e-mail, and US mail with Field Network staff and Provider community regarding contract documentation questions, issues, and or concerns.
• Reviews contractual documents for completeness.
• Determine appropriate network participation status; investigate accuracy of affiliations and contract/rate documents. Communicate with other Network staff to ensure accuracy of rates and reimbursement to providers.
• Link group members to appropriate group practices. Ensure accuracy of TIN and service addresses. Ensure accuracy of affiliation status based upon group affiliations.
• Execute appropriate contractual document; update affiliations in the provider database to reflect participation status, request correspondence to providers to communicate contract status and effective dates; create website logins for providers.

Qualifications:

• Ability to type an average of 40 WPM.
• Working knowledge of MS Office Suite and ability to learn new software applications quickly and efficiently.
• 1-3 years of customer service experience.
• Experience working in a Credentialing or Contracting department for Provider Network Services.

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