Payor Credentialing Specialist

Payor Credentialing Specialist

Requirements

• Minimum 2 – 4 years’ experience in credential verification or in a Physician practice/Medical office or other similar experience in a healthcare setting; or Associates Degree in Business, HealthCare Administration, or other related field with 1 – 2 years’ experience.
• Strong detail orientation required, with the ability to administer multiple tasks and prioritize.
• Excellent verbal and written communication skills.
• Ability to positively interact with providers, hospital personnel, and other internal and external contacts.
• Perform work at a high level of accuracy and timelines.
• Attention to confidentiality and regard for protecting confidential and sensitive information.
• Advanced level skills with Microsoft Access, Excel, and Word.
• Strong problem solving and time management skills with the ability to consistently work in a fast-paced environment.
• Strong Excel, data-base management, and document storage and management skills.

Responsibilities

• Verify the qualifications and professional credentials (licenses, certifications, education, etc.) of healthcare providers (doctors, nurses, clinics, etc.).
• Ensure all providers meet the standards and requirements set by insurance companies, government programs (like Medicare/Medicaid), and other payers.
• Assist healthcare providers in completing credentialing applications and ensuring all required documentation is submitted.
• Ensure that applications are complete, accurate, and meet all necessary criteria to avoid delays or rejections.
• Verify important provider details, such as medical licenses, board certifications, educational history, work experience, malpractice history, and other relevant qualifications.
• Confirm that healthcare providers have a clean record and no history of disciplinary actions.
• Maintain and update accurate records of credentialed providers, ensuring that all required documentation is current and stored securely.
• Track expiration dates for licenses, certifications, and other credentials to ensure timely renewal and uninterrupted participation in payer networks.
• Submit applications and documentation to insurance companies or other payers for healthcare provider enrollment.
• Ensure providers are properly enrolled in payer networks, allowing them to be reimbursed for services provided to insured patients.
• Track and follow up on the status of credentialing and enrollment applications to ensure timely approval and avoid disruptions in provider participation.
• Communicate with both healthcare providers and payer representatives to resolve any issues or delays in the credentialing process.
• Ensure that healthcare providers comply with all applicable regulations, policies, and payer-specific requirements for credentialing and participation in insurance networks.
• Stay updated on changes to credentialing standards, healthcare regulations, and payer requirements.
• Manage the re-credentialing process, ensuring that providers’ credentials are renewed before expiration.
• Address and resolve any discrepancies, concerns, or issues that arise during the credentialing process, working closely with both healthcare providers and payer representatives.
• Act as the point of contact between the healthcare providers and the payer organizations to facilitate smooth communication and resolve any credentialing issues.

Preferred Qualifications

• Associates Degree in Business, HealthCare Administration, or other related field desirable.

Benefits