Credentialing specialist

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion : PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Responsible for obtaining and maintaining critical provider credentialing data necessary for initial and recredentialing reviews to determine participatory status, ensuring selection of providers who possess and maintain the clinical skills necessary to deliver high quality of healthcare and service excellence to PacificSource members.

Follow credentialing procedures, accreditation and regulatory requirements to ensure timely, accurate credentialing of practitioners affiliated with PacificSource.

Essential Responsibilities :

• Input and maintain practitioner data in computer database. Review, research and verify practitioner files and computer database records to obtain information and compile data for reports.
• Perform essential credentialing activities related to credentialing and recredentialing operations. Organize project work, maintain inter-departmental contacts regarding credentialing issues, and maintain credentialing status report.
• Conduct primary source verification on applicants, which may include but is not limited to : making requests, investigations, verifications of multiple documents, tracking and follow-up of responses from all required sources as required by accreditation and regulatory requirements and credentialing policies and procedures.
• Maintain familiarity with requirements of National Practitioner Data Bank (NPDB), State Medical Boards, the National Committee of Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), PacificSource credentialing policies and procedures and other requirements as applicable.
• Manage and respond to high volume internal and external customer inquiries and correspondence via email, telephone and in person.
• Collaborate and work cohesively in a team environment with reassignment of primary job responsibilities and duties as necessary to ensure high productivity and work process efficiency.
• Maintain collaborative relationships and act as liaison between PacificSource and IPAs / Delegates, practitioners and their staff and other contacts to ensure excellent customer service and accurate information is obtained and entered in the system.
• Review monthly reports to ensure all practitioners complete recredentialing in accordance with the assigned target date.

Perform projects including generation and review of reports and data entry corrections to improve system integrity and compliance.

• Prepare reports and written summaries on practitioners with adverse actions identified during the credentialing process for the Credentialing Committee and develop meeting materials in preparation of the monthly meeting.
• Maintain strict confidentiality of all practitioners' records, data, correspondence and occurrences.

Supporting Responsibilities :

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience : Minimum of two years health insurance experience or equivalent required, credentialing experience preferred.

Education, Certificates, Licenses : High School Diploma or equivalent required, Associate Degree preferred. NAMSS Certified Provider Credentialing Specialist Certification (CPCS) preferred.

Knowledge : Effective written and verbal communication skills. Must be highly organized and possess strong interpersonal skills.

Knowledge of NCQA credentialing standards as well as state and regulatory credentialing requirements. Knowledge of policy and procedure development.

Computer skills, including word processing, spreadsheets, and database applications is required. Ability to tactfully interact with medical practitioners, staffs and handle a variety of situations is required.

Excellent organizational and communications skills required.

Competencies : Adaptability

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment : Work inside in a general office setting with ergonomically configured equipment. Some travel may be required 5% of time for training, external meetings and credentialing audits.

Work hours may include early mornings, evenings, and out of town travel, occasionally overnight.

Skills :

Accountability, Collaboration, Communication (written / verbal), Flexibility, Group Problem Solving, Listening (active), Organizational skills / Planning and Organization, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business :

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements : Stoop and bend. Sit and / or stand for extended periods of time while performing core job functions.

Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English.

Communicate clearly and effectively.

Disclaimer : This job description indicates the general nature and level of work performed by employees within this position and is subject to change.

It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position.

Employment remains AT-WILL at all times.

Last updated : 2024-05-09