Credentialing Specialist

Point32Health; Milton (MA); On-site; USD 52,000 - 60,000; Full time

Job summary

Point32Health, Inc. is seeking a Credentialing Specialist to ensure physicians and independent practitioners meet health plan criteria and regulatory standards.

The role focuses on credentialing data integrity, license verification, and timely processing aligned with NCQA guidelines. Responsibilities include managing credentialing applications, NPDB screening, and supporting daily reviewer processes while collaborating with the Medical Director and Supervisors to resolve issues and ensure

Qualifications

• A minimum of a high school diploma is required.
• Bachelor’s degree is preferred.
• 1-2 years of experience in healthcare is required.
• Experience with provider credentialing is preferred.
• Knowledge of Word and Excel is recommended.

Responsibilities

• Maintain and process credentialing information for new and established providers.
• Enter initial and existing credentialing applications into the credentialing information system (Cactus).
• Verify licenses, board certifications, and related documentation.
• Review NPDB reports and state/federal sanctions as applicable.
• Prepare files for credentialing reviews and for QOCC presentations.
• Collaborate with Credentialing Supervisor on complex issues and regulatory requirements.

Skills

Emergency protocol

Credentialing system

Multi-tasking

Adaptability

Education

High school diploma

Bachelor’s degree

Tools

MS Word

MS Excel

Job description

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

The Credentialing Specialist is responsible for ensuring all Point32Health affiliated physicians and other independent practitioners and allied providers are qualified to provide health care services to members in accordance with Point32Health’s policies and procedures, state laws and/or regulatory requirements (e.g., NCQA). Practitioners are recredentialed at least every three years or more frequently as required.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Essential functions occur simultaneously, therefore, the employee must be able to appropriately handle each essential function, prioritize them, and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment. Requires the ability to learn and apply Point32Health policies consistently and seek out guidance when necessary.
• Responsible for maintaining and processing physician and provider credentialing information for new and established health plan practitioners in accordance with Point32Health’s policies and procedures, state laws and regulatory agencies, including but not limited to:
• Assessment of adequate and accurate information for participation in Point32Health, including a limited knowledge of provider contract information.
• Accurate and timely entry of initial and existing credentialing applications into the credentialing information system (Cactus).
• Verification through various sources of necessary licenses, board certification, etc.
• Review and report of adverse information received through National Practitioner Data Bank (NPDB), state and federal sanctions.
• Retrieval of missing and/or expired information/documentation required for credentialing.
• Act as resource for physician and provider questions relating to certification and/or credentialing process.
• Identify for Credentialing Supervisor those issues of broader complexity or sensitivity that may require further action by a Medical Director or other outside source.
• Daily, prepare files that Meet Credentialing Criteria for review by the Credentialing Compliance Coordinator and/or Supervisor and presentation to daily Medical Director file review.
• Prepare files that may not Meet Credentialing Criteria for review by the Medical Directors and/or Senior Credentialing Specialist and/or Supervisor and presentation to the Quality-of-Care Committee (QOCC), including report of adverse information.
• Daily, process all practitioners under the terms and conditions of the entities’ agreement, including files credentialed through a Certified Verification Organization (CVO).
• Participate in task forces and/or other meetings as assigned and execute other responsibilities as assigned.
• Other duties and projects as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

Education

• Required (minimum): High school diploma
• Preferred: Bachelor’s degree

Experience

• Required (minimum): 1-2 years of experience in healthcare field. Experience with personal computer.
• Preferred: Experience with provider credentialing. Knowledge Word and Excel.

Skill Requirements

• All information (written, verbal, electronic, etc.)
• Ability to appropriately identify emergency situations and follow the appropriate protocol.
• Must have the ability to maintain and manipulate a complex credentialing information system.
• Must be able to prioritize multiple tasks and achieve deadlines.
• Must have ability to adapt to changing environment.