Overview: As a Credentialing Executive, you will play a crucial role in ensuring that our healthcare organization maintains compliance with regulatory standards and delivers high-quality care by thoroughly vetting and credentialing healthcare providers Your attention to detail, understanding of healthcare regulations, and ability to build strong relationships will be instrumental in facilitating the credentialing process and maintaining accurate provider databases. Responsibilities: Provider Credentialing: Manage the credentialing process for healthcare providers, including physicians, nurse practitioners, physician assistants, and allied health professionals This involves collecting, verifying, and evaluating provider credentials, licenses, certifications, and other relevant documents to ensure compliance with organizational and regulatory standards. Provider Enrollment: Coordinate provider enrollment with various insurance networks, Medicare, Medicaid, and other payer organizations Complete and submit enrollment applications accurately and in a timely manner to facilitate reimbursement for services rendered by credentialed providers. Database Management: Maintain accurate and up-to-date provider databases, including credentialing files, licensure information, malpractice insurance coverage, and other pertinent documentation Ensure that all provider information is entered and updated in credentialing software systems or databases. Regulatory Compliance: Stay abreast of changes in healthcare regulations, accreditation standards, and payer requirements related to provider credentialing and enrollment Ensure that credentialing processes align with industry best practices and regulatory guidelines, including those set forth by organizations such as NCQA, URAC, and CMS. Provider Relationships: Develop and maintain positive relationships with healthcare providers, medical staff, and internal stakeholders to facilitate the credentialing process Serve as a liaison between providers and credentialing committees, addressing inquiries, resolving issues, and providing support as needed. Quality Assurance: Implement quality assurance measures to monitor the effectiveness and efficiency of the credentialing process Identify areas for improvement and implement corrective actions to enhance process efficiency, accuracy, and compliance. Audits and Reviews: Prepare for and participate in internal and external audits, reviews, and accreditation surveys related to provider credentialing and enrollment Ensure that credentialing documentation and processes meet audit requirements and support organizational compliance. Training and Education: Provide training and education to healthcare providers and staff on credentialing policies, procedures, and best practices Foster a culture of compliance and accountability throughout the organization by promoting awareness of credentialing requirements and expectations. Qualifications: Bachelor's degree in healthcare administration, business administration, or a related field (Master's degree preferred). Certification in healthcare credentialing (e.g., CPCS, CPMSM) highly desirable. Minimum of 3-5 years of experience in healthcare credentialing and provider enrollment, preferably in a managed care. In-depth knowledge of healthcare regulations, accreditation standards, and payer requirements related to provider credentialing and enrollment (e.g., NCQA, CMS, Medicare). Proficiency in credentialing software systems (e.g., CAQH, NAMSS) and Microsoft Office Suite. Strong analytical skills with the ability to review and interpret complex credentialing documents and data. Excellent communication, interpersonal, and organizational skills. Detail-oriented with a commitment to accuracy and quality assurance. Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.
