Credentialing Coordinator- Temporary

Provider Partners; United States; On-site; USD 52,000 - 78,000; Full time

Job summary

Provider Partners is seeking a Credentialing Specialist to verify credentials and manage provider data for network participation. You will ensure compliance with regulatory standards and maintain accurate information across systems.

Responsibilities include primary source verification, handling inquiries, updating files, and audits to ensure CMS and NQA compliance. Strong Excel skills and Salesforce expertise are valued.

Qualifications

• Education and experience align with credentialing operations.
• Proven ability to manage provider data and comply with regulatory standards.

Responsibilities

• Analyze credentialing applications for primary source verification and determine network eligibility.
• Respond to inquiries about provider participation, eligibility, credentialing, and file updates.
• Maintain provider files, Salesforce workflow, and electronic records with current data.

Skills

Excel

Pivot tables

Communication

Interpersonal skills

Education

High School Diploma

Bachelor’s Degree in Business/Healthcare Admin or related field

Tools

Salesforce

Job description

Purpose

This role will credential practitioners for network participation with PPHP and accurately maintain all provider data within SF to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.

Essential Functions

• 35% Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the PPHP networks. Once verified, accepted and approved, determines the appropriate networks and notifies provider.


• 20% Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, and provider file updates. Direct focus on the provider experience, providing timelier resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved. Professional etiquette, communications and sound decision making is required.


• 20% Maintains the provider file, the Salesforce (SF) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities.


• 10% Responsible for identifying, analyzing and resolving immediate and existing provider file issues. Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered into the provider file database, ensuring a successful integration with the other corporate systems.


• 10% Audits all delegated entities on an annual basis to ensure compliance with CMS and NQA standards.


• 5% Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education Level: High School Diploma


• Experience: 3 years health insurance/managed care credentialing operations experience. 2 years of Delegated Credentialing Auditing.


• Preferred Qualifications: Bachelor’s Degree in Business, Healthcare Administration or related field

Knowledge, Skills And Abilities (KSAs)

Proficient: Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables. Proficient: Excellent verbal and written communication and interpersonal skills. Ability to develop and