Credentialing and Contracting Medical Provider Network Specialist Job Opening in Fresno, CA at Tristar Insurance

Job Posting for Credentialing and Contracting Medical Provider Network Specialist at Tristar Insurance

Job Details

Level: Experienced

Job Location: Fresno Office - Fresno, CA

Position Type: Full Time

Education Level: High School Diploma or GED

Salary Range: $17.00 - $19.00 Hourly

Travel Percentage: 20%

Job Shift: Day

Job Category: Insurance

Credentialing & Contracting Medical Provider Network Special

This will be a remote position.

JOB SUMMARY:

The Credentialing and Contracting Specialist is responsible for preparing and maintaining contracts and the contracts database system. Maintain active status for all providers by successfully completing initial and subsequent credentialing packages as required by state regulations, guidelines and policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, the employee must be able to efficiently and effectively perform each of the following essential functions. Reasonable accommodation may be made for individuals with disabilities.

The functions of this job include but are not limited to;

Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with regulations, guidelines, policies, and standards. Monitors Applications and follows-up as needed.
Conducts primary source verification, collects and validates documents (state license, DEA Certificates, malpractice coverage, etc.) to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards to ensure timely renewal. Maintains provider contract files.
Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners; discovers and conveys problems to Director for sound decision making in accordance with credentialing policies and procedures, state regulations.
Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures.
Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
Participates in the development and implementation of process improvements for the credentialing process.
Communicates clearly with providers, their liaisons, and staff as needed to provide timely responses upon request on day-to-day credentialing, provider, staff and client issues as they arise.
Assist in helping find available physician(s) when unavailable within the Network.
Maintains professional growth and development through professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
Performs miscellaneous job-related duties as assigned.

SUPERVISORY RESPONSIBILITIES:

(N/A)

Qualifications

QUALIFICATION REQUIREMENTS:

Ability to communicate effectively both orally and in writing.
Customer service skills.
Ability to respond to emails timely and effectively.
Information research skills.
Knowledge of medical provider credentialing and accreditation principles, policies, processes, procedures, and documentation.
Ability to use independent judgment and to manage and impart confidential information.
Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and/or applications.
Ability to make administrative/procedural decisions and judgments.
Demonstrated advanced working knowledge of Microsoft Word and Excel.
Ability to learn new applications to function effectively in a remote work environment.
Skill in establishing priorities with independent coordination of day-to-day aspects.
Skills in computerized spreadsheets and database management.
Ability to organize and prioritize work and manage multiple priorities.

EDUCATION and/or EXPERIENCE:

High school diploma or equivalent required.
Computer skills required with knowledge in utilizing Outlook, Microsoft Word, Excel and other databases.

LANGUAGE SKILLS

Extensive clear, professional and tactful communications required via writing, reading, telephone calls, note taking, letter writing, memoranda, etc. Must be able to follow instruction and pay close attention to detail.

PHYSICAL DEMANDS

The physical demand described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, talk and hear.
The employee frequently is required to use hands to operate a computer keyboard, handle or feel and reach with hands and arms.
The employee is occasionally required to stand and walk.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
The employee must frequently be able to communicate clearly in person or over the phone.
No or very limited exposure to physical risk.
Work is normally performed in a typical interior/office work environment.

WORK ENVIROMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually quite

Here are some of the benefits you can enjoy in this role:

Medical, Dental, Vision, Disability & Life Insurance
401(k) plan
Paid time off.
Paid holidays.

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT

a. Reasoning development::

X Follow one- or two-step instructions; routine, repetitive task.

Carry out detail but uninvolved written or verbal instructions; deal with a few concrete

variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

b. Mathematical development:

Simple additional and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

X Arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c. Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

X Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2. PHYSICAL EFFORT

a. Physical activity required to perform the job:

Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

X Light work:

a. Exerting up to 20 pounds of force occasionally

b. Exerting up to 10 pounds frequently

c. Exerting a negligible amount of force constantly to move objects

(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work:

a. Exerting up to 50 pounds of force occasionally

b. Exerting up to 20 pounds of force frequently

c. Exerting up to 10 pounds of force constantly to move objects

Heavy work:

a. Exerting up to 100 pounds of force occasionally

b. Exerting up to 50 pounds of force frequently

c. Exerting up to 20 pounds of force constantly to move objects

Very heavy work:

a. Exerting in excess of 100 pounds of force occasionally

b. Exerting in excess of 50 pounds of force constantly to move objects

c. Exerting in excess of 20 pounds of force constantly to move objects

Visual requirements necessary to perform the job:

Far vision: clarity of vision at 20 feet or more

X Near vision: clarity of vision at 20 inches or less

X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet

Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are

Color vision: ability to identify and distinguish colors

Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point

c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally): Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion. Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. X Kneeling: Bending legs at knee to come to a rest on knee or knees. X Crouching: Bending the body downward and forward by bending legs and spine. Crawling: Moving about on hands and knees or hands and feet. X Reaching: Extending hand(s) and arm(s) in any direction. X Standing: Particularly for sustained periods of time. X Walking: Moving about on foot to accomplish tasks, particularly for long distances. X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward. X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. Foot Motion: Using feet to push pedals. X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles. X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling. X Grasping: Applying pressure to an object with the fingers and palm.	Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Frequently Occasionally
	2. PHYSICAL EFFORT (cont.)
	X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts. Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips. X Repetitive Substantial movements (motions) of the wrists, hands, Motion: and/or fingers.
	3. WORKING CONDITIONS Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.
	WORKING CONDITION ENVIRONMENTAL FACTOR	NATURE/REASON OF EXPOSURE	FREQUENCY
	Dirt/Dust
	Noise
	Temperature extremes
	Dampness
	Vibrations
	Equipment movement hazard
	Chemicals/solvents
	Electrical shock

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Credentialing and Contracting Medical Provider Network Specialist

Job Posting for Credentialing and Contracting Medical Provider Network Specialist at Tristar Insurance

Job Details

Credentialing & Contracting Medical Provider Network Special

Qualifications

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