Provider Credentialing Specialist I (Remote)

CareFirst BlueCross BlueShield; Baltimore (MD); On-site; USD 38,520 - 70,620; Full time

Job summary

CareFirst BlueCross BlueShield seeks a Credentialing Specialist to verify credentials and manage provider data for network participation in Baltimore. You will maintain the provider file, support recredentialing, and ensure compliance with regulatory standards.

The role requires attention to detail, strong communication, and proficiency with data systems. Qualified candidates typically have 3 years of credentialing or related health insurance experience, a high school diploma or GED, and

Qualifications

• 3 years physician credentialing or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.
• Proficiency in Excel and Pivot tables.
• Understanding of credentialing processes and regulatory requirements.

Responsibilities

• Analyzes credentialing applications for primary source verification for network participation.
• Responds to inquiries regarding provider participation eligibility and credentialing status.
• Maintains provider files and related data systems with updates during credentialing and recredentialing.
• Identifies and resolves provider file issues and ensures data accuracy across systems.
• Prepares written responses to obtain incomplete or missing information.

Skills

Excel

Pivot tables

Verbal communication

Interpersonal skills

Medical terminology

Education

High school diploma or GED

Bachelor's degree in Business or Healthcare Administration

Tools

PICS inventory system

Job description

Purpose

This role will credential practitioners for network participation with CareFirst BlueCross BlueShield and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.

Responsibilities

• Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the CareFirst networks. Once verified, accepted and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.
• Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, contractual status and provider file updates. Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved. Professional etiquette, communications and sound decision making is required.
• Maintains the provider file, the Provider Information Control (PICS) 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.
• 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.
• Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

Qualifications

Education Level: High School Diploma or GED.

Licenses/Certifications Preferred:

• Certified Provider Credentialing Specialist (CPCS)

Experience: 3 years physician credentialing experience or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.

Preferred Qualifications:

• Bachelors Degree in Business, Healthcare Administration or related field.

Knowledge, Skills And Abilities (KSAs):

• Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables.
• Excellent verbal and written communication and interpersonal skills. Ability to develop and maintain effective relationships with peers, physicians, and medical staff to create confidence, respect and dependability.
• Knowledge of medical terminology.
• Demonstrated proficiency utilizing reference materials and ability to follow Standard Operating procedures to reduce risk and ensure provider data accuracy and overall quality.
• Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes and interpret reasoning for performing verification and/or appropriate actions.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range

$38,520 - $70,620

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disqualification / Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.