Credentialing Specialist

Triple-S; Guaynabo (PR); On-site; USD 45,000 - 60,000; Full time

Job summary

Triple-S is seeking a credentialing professional to independently perform tasks based on policies and procedures. You will gather information, conduct analysis, and make recommendations for credentialing and re-credentialing processes while ensuring policy alignment and regulatory compliance.

Responsibilities include reviewing provider applications, coordinating information from internal and external sources, maintaining credentialing records, and preparing reports to support department metrics.

Qualifications

• Associate degree or 60–64 college credits with 1–3 years related experience.
• Experience with credentialing or procurement processes preferred.

Responsibilities

• Reviews provider applications and ensures documentation is complete per requirements.
• Coordinates information from internal and external sources for credentialing.
• Updates credentialing data in software and tracking tools.
• Acts as primary contact for provider inquiries related to credentialing.
• Prepares reports on credentialing activities and maintains metrics.
• Audits credentialing files for regulatory compliance and policy adherence.
• Manages confidential provider information according to policy.
• Participates in projects to implement credentialing systems and procedures.
• Performs additional tasks as assigned by supervisor.

Skills

Action Oriented

Collaborates

Customer Delight (Employee)

Instills Trust

Manages Ambiguity

Education

Associate's Degree

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

Job Summary

Independently performs tasks that require knowledge and implementation of policies, procedures, and general methods of operation. Responsible for collecting information based on facts, conducting research and analysis and making recommendations that will be used by others to a higher hierarchical level. Evaluates complex situations that require application and knowledge of policies, methods, and procedures for recruitment. The use of the trial is focused on collecting, organizing, and presenting information relevant to a situation or problem, channeling the supervisor those unusual situations, or not covered by procedures. Collaborate and participate in functions related to the procurement process, credentialization and in the development of strategies to maintain the adequacy of the network.

Essential Functions

• Reviews Provider’s application and ensures that it has been appropriately completed with all required documentation according to the provider specialty, provider type and or contracted services as required by the federal regulatory (CMS), local government requirements (ASES), URAC Accreditation and company’s policies and procedures as part of the credentialing and re credentialing processes.
• Coordinates obtaining information from internal and external (Primary and Secondary Sources) sources to ensure receipt of the necessary documents to complete the Credentialing process and, or Re-credentialing process documentation.
• Updates Credentialing and Re-credentialing information and documentation in the credentialing software’s and, or tracking tools.
• Contact the Provider’s as needed (via email and, or phone) to ensure receipt the documents to complete the credentialing process or re credentialing.
• Prepares reports related to the credentialing and re credentialing process activities for supports tracking and maintenance of metrics for the department.
• Prepares and audits the file containing the documentation in accordance with criteria established by the regulatory agencies and company’s policies and procedures for review and determination by the Credentialing Committee.
• Manages confidential Provider’s information according to policies, procedures, and applicable regulations.
• Daily acts as the primary point of contact and liaison for all internal and external customers on issues, concerns, questions, or situations of the credentialing process.
• Participates in projects and assists in the implementation of systems and procedures to ensure that all credentials and accreditation processes are performed according to the regulations, policies, and standards.
• Performs other task related as assigned by the supervisor and that are essential to the corporation's objectives and division operational plans.

EDUCATION

• Associate's Degree

Experience

Associate degree (AD) or at least 60-64 college credits, with one (1) to three (3) years of related experience.

LICENSES AND CERTIFICATIONS

• None required

COMPETENCIES

• Action Oriented
• Collaborates
• Customer Delight (Employee)
• Instills Trust
• Manages Ambiguity

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.