Credentialing Specialist

Point32Health, Inc.; United States; On-site; USD 33,000 - 50,000; Full time

Job summary

Point32Health, Inc. is seeking a Credentialing Specialist to ensure physicians and independent practitioners meet policy and regulatory requirements for participation in our health plans.

You will manage credentialing applications, verify credentials, and review NPDB and sanctions information, while collaborating with the Credentialing Compliance Coordinator and Medical Directors to keep files current and compliant.

Qualifications

• High school diploma required; bachelor’s degree preferred.
• 1–2 years of healthcare experience; credentialing experience preferred.
• Proficient in Word and Excel; strong written and verbal communication.

Responsibilities

• Maintain and process physician/provider credentialing information per policies and regulations.
• Enter credentialing applications into the Cactus system accurately and timely.
• Verify licenses, board certifications, and other credentials.
• Review adverse information from NPDB and state/federal sanctions.
• Prepare credentialing files for review by Credentialing Supervisor and Medical Directors.
• Identify issues requiring escalation to Medical Director or outside sources.
• Support daily file reviews and participation in related committees.
• Contribute to task forces and other initiatives as needed.

Skills

Credentialing

Attention to detail

Communication

Time management

MS Office

Education

High school diploma

Bachelor’s degree

Tools

Cactus system

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.
• Strong written and verbal skills are necessary.
• Individual must possess initiative, judgement, exceptional organizational skills and keen attention to detail.
• Must be able to work and process time-sensitive information.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$24.10 -$36.16

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company’s sole discretion and maybe modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all

All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.