Position Summary:
The Provider Relations Specialist ensures full compliance of the Provider Network with federal and state regulations regarding licensure and certification. This key individual will track all issues associated with activities necessary to maintain ongoing compliance with policy and procedures. The Provider Relations Specialist prepares assists and monitors all activities related to initial credentialing, re-credentialing and credential modification. The employee will ensure full confidentiality of credentialing process.
Essential Functions:
1. Prepares credentialing and re-credentialing applications for process review, assuring an efficient and compliant process according to policies and procedures; Communicates with clients and/or practitioners regarding incomplete, inaccurate or conflicting credentialing information; accepts additional information from practitioners to correct such incomplete, inaccurate, or conflicting credentialing information. (10%)
2. Completes the provider application and collects credential documents; Reviews and maintains accuracy of provider credentialing documents.
3. Requests and monitors state licensure and good standing as well as Board Certification-when applicable-from the License Professional Board and/other regulatory agencies; Requests and verifies
credential information with educational institutions; (10%)
4. Greets contracted providers and external clients at Central Office. (10%)
5. Completes data entries, updates information and monitors accuracy applications within the system. (10%)
6. Prepares re-credentialing aging reports and sends provider notifications of re-credentialing before due date; Coordinates, prepares and presents monthly reports for the Credentialing Committee Meeting. (10%)
7. Monitors and ensures that credential files are properly completed and current pursuant to expiration date of medical licenses, board certification, professional-liability insurance coverage, DEA and other pertinent information per APS policy and timely notifies managers of any issue identified during the process. (10%)
8. Collaborates with the Claims Department to improve workflow and overall customer service. (10%)
Coordinates
9. Credentialing Committee meetings when needed; Prepares documents and mail when needed; Answers the provider's "Queue" phone system when needed. (10%)
Other Duties:
10. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS)
and guidelines set forth by other regulatory agencies, where applicable. (10%)
11. In addition, all other duties assigned by the manager and/or supervisor. (10%)
Education:
High School Diploma.
Bachelor's degree preferred.
Experience:
Minimum 1 year of experience in credentialing in a health industry preferred.
