Credentialing and Contracting Medical Provider Network (MPN) Specialist

This is a remote position. Prefer candidates to be remote in Texas.

JOB SUMMARY:

The Credentialing and Contracting Specialist is responsible for preparing and maintaining contracts and the contracts database system. Maintain active status for all providers by successfully completing initial and subsequent credentialing packages as required by state regulations, guidelines and policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, the employee must be able to efficiently and effectively perform each of the following essential functions. Reasonable accommodation may be made for individuals with disabilities.

The functions of this job include but are not limited to;

• Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with regulations, guidelines, policies, and standards. Monitors Applications and follows-up as needed.
• Conducts primary source verification, collects and validates documents (state license, DEA Certificates, malpractice coverage, etc.) to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards to ensure timely renewal. Maintains provider contract files.
• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to Director for sound decision making in accordance with credentialing policies and procedures, state regulations.
• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
• Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
• Participates in the development and implementation of process improvements for the credentialing process.
• Communicates clearly with providers, their liaisons, and staff as needed to provide timely responses upon request on day-to-day credentialing, provider, staff and client issues as they arise.
• Assist in helping find available physician(s) when unavailable within the Network.
• Maintains professional growth and development through professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
• Performs miscellaneous job-related duties as assigned.

SUPERVISORY RESPONSIBILITIES:

(N/A)