Credentialing Specialist: Compliance & Process Leader

RiseMe; Detroit (MI); On-site; USD 52,000 - 70,000; Full time

Job summary

RiseMe is seeking a credentialing professional to process practitioner and organization provider applications in accordance with State and Federal regulations and NCQA standards. You will request and verify primary source documentation, update the system of record, and categorize cases for reporting to the Medical Director and Credentialing Committee.

In this role you will resolve file disposition inquiries, support Credentials Committee meetings, and assist with special projects.

Qualifications

• Associate degree preferred.
• 2–5 years of work experience in provider enrollment, contracting, medical practice or hospital business office role and/or credentialing related field required.
• Knowledge of state and federal regulations, NCQA, DIFS, MDHHS and CMS standards for credentialing required.
• Knowledge of CAQH required.
• Excellent organizational skills with attention to detail required.
• Excellent verbal and written communication skills required.
• Ability to handle and prioritize multiple case files and timelines required.
• Ability to work effectively independently or in a team environment required.

Responsibilities

• Process practitioner and organization/facility provider applications for credentialing and recredentialing; requesting primary source documentation, processing documentation requirements, verifying information received, updating information in the system of record, evaluating over all case categorization and reporting findings to the Medical Director and Enterprise Credentialing Committee.
• Resolve inquiries related to credentialing file disposition.
• Provide credentialing status information for group administrators, physicians and their staff, Provider Services, Customer Service and Network Development Inquiries.
• May be designated by the leader to attend Credentials Committee meetings and conduct internal meetings and participate in auditing processes.
• Assist with special projects and job aids as needed.

Skills

Organizational skills

Time management

Verbal and written communication

Independent and team work

Attention to detail

Education

Associate degree preferred

Tools

Microsoft Word

Microsoft Excel

Microsoft Access

PowerPoint

Internet proficiency

Job description

RiseMe is seeking a credentialing professional to process practitioner and organization provider applications in accordance with State and Federal regulations and NCQA standards. You will request and verify primary source documentation, update the system of record, and categorize cases for reporting to the Medical Director and Credentialing Committee.

In this role you will resolve file disposition inquiries, support Credentials Committee meetings, and assist with special projects.