Credentialing Specialist

Pinehurst Surgical Clinic   Pinehurst, NC   Full-time     Health Care Provider
Posted on September 16, 2022
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SUMMARY:

Under general supervision, the Credentialing Specialist is responsible to credential and privilege all providers accurately and in a timely manner.

PERSONAL CHARACTERISTICS:
  1. Maintains confidentiality
  2. Detail oriented
  3. Comprehends technical information
  4. Independently works with others in a wide variety of circumstances
  5. Ability to prioritize


Requirements

POSITION REQUIREMENTS:
  1. Initial Credentialing
  2. Processes initial applications for physicians and advanced practice providers
  3. Assists new providers in obtaining their license and DEA
  4. Starts malpractice coverage process to add new providers
  5. Contacts all new providers on a weekly basis to answer questions and guide them through the credentialing process
  6. Monitors applications and provides updates to applicants and documents in the credentialing system
  7. Executes queries for the National Practitioner Data Bank (NPDB) for initial appointment through NPDB Continuous Query in the Credentialing database.
  8. Contacts government and private payors to track progress and assure that credentialing timelines are met.


  1. Recredentialing
  2. Updates the CAQH on all existing providers every 120 days. Maintains credentials database with up-to-date practitioner information, including medical license, drug enforcement administration (DEA) certificate professional liability insurance, board certifications and renewal period expiration dates
  3. Tracks licenses and DEAs in credentialing system and communicates concerning deadlines with managers, secretaries and providers
  4. Compiles and maintains current and accurate data for all providers
  5. Ensures physician practice demographic information is compliant with health plans, agencies and other entities
  6. Provides credentialing, re-credentialing and privileging verifications in accordance with regulatory standards, and state/federal laws
  7. Credentials new providers and re-credential current providers with hospitals and Surgery Centers where they hold staff privileges


  1. Privileging
  2. Ensures completion of privileging requests for initial privileging for all providers with supporting documentation including residency, fellowship, board certification and evidence of proctoring by an experienced surgeon and CEU Program with a certificate
  3. Renews privileges for all providers every three years
  4. Ensures that ancillary testing privileges delineate either review or interpretation for each ancillary test depending upon the provider's education, training, and/or practice agreement
  5. Maintains privileging files in a location and filing system easily accessed by all managers


  1. Malpractice Insurance
  2. Adds new providers
  3. Deletes terminated or retired providers
  4. Obtains and maintains updated Certificates of Insurance (COIs)
  5. Responds to questionnaires and inquiries


  1. General Administrative Duties
  2. Responds quickly to requests from providers, employees, and outside inquirers
  3. Pursuit of personal professional development
  4. Provides training as requested
  5. Other projects and tasks as assigned


PREFERRED QUALIFICATIONS:
  1. Associates degree in business or medical related field
  2. Three years medical administrative experience
  3. Types 65 WPM
  4. Microsoft Office Suite: intermediate skill level
  5. Basic math including: fractions, percentages, and ratios
  6. Knowledge of medical terminology