Credentialing Specialist

GENERAL SUMMARY

The Credentialing Specialist is responsible for the timely management of credentialing for all providers at Sound. Success in this role depends upon developing expert level awareness of regulatory, governing and operating criteria related to the delivery of our clients’ care.

ESSENTIAL RESPONSIBILITIES

• Responsible for all aspects of initial credentialing, recredentialing, and privileging of practitioners or providers within the credentialing scope who are employed or contracted with Sound.
• Collect and verify provider and practitioner information through primary sources for initial appointment and for re-appointment within established time frames and in accordance with the standards required by accrediting/regulatory agencies.
• Maintain all rosters and panels with all payers per the requirements of each payer.
• Responsible for timely registration of all new clinical team members with the Health Care Authority, per their requirements, and utilizing the ProviderOne system.
• Participate in meetings related to Accounts Receivable and take action on issues identified that pertain to payer credentialing or roster denials.
• Maintain confidentiality of provider files and all information related to the credentialing process.
• Audit files based on Sound and regulatory standards.
• Audit applications for completeness, accuracy and essential criteria to meet required standards.
• Create and maintain credentialing database to keep data current and accurate.
• Run standard reports to monitor work and ensure completion of applications in a timely manner.
• Provide written and verbal communication with federal, state, local agencies and others to obtain provider and practitioner information.
• Assess, evaluate and interpret application and verification information to identify 'red flags' or areas of established non-compliance. Communicate adverse, incomplete, or questionable data to Medical Director, Credentials team, or designee and recommend appropriate course of action.
• Participate in preparation for internal and external audits conducted for current and accurate provider information or delegation compliance.
• Coordinate Credentialing Review meetings and agendas, including minutes and follow up action
• Keep track of pended information and follow up in an appropriate timeframe.
• Provide assistance with special projects.
• May scan working documents, make copies, assist with mass mailings, distribute faxes and/or help file correspondence and pertinent materials.
• Participate in research, review and interpretation of applicable accreditation, licensing, and other regulatory requirements to ensure credentialing policies and policies continually meet requirements.
• Participate in design and development of forms to support credentialing
• Assist other internal departments with application completion and systems coordination activity.
• Provide status reports and communicate practitioner participation information to internal and external customers.
• Maintain written and verbal communication related to all credentialing activities with Manager and Director. 
  
  

KEY WORK RELATIONSHIPS

Collaborates with other Sound teams to ensure proper paneling and coordination for our prescribers.

Establishes and maintains positive, ethical, and professional working relationships with the Administrative Services team, Sound management and team members, clients, visitors, vendors, and other professionals.

EDUCATION AND EXPERIENCE 

• Associate's degree OR two (2) years of directly related experience in a clinical setting.
• Certified Provider Credentialing Specialist (CPCS) is required or 5 years of current, relevant experience in lieu of certification
• Experience in managed care, hospital or medical office environment.
• Experience in Health Care Authority registration regulations and Provider One system.
• Demonstrated ability to manage multiple priorities and competing deadlines.
• Solid computer skills, with proven knowledge of database maintenance, Excel and Word.
• Communication Skills 
• Bachelor's degree with coursework in healthcare, preferred
• Behavioral health credentialing experience, preferred

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of administrative functions, including phones, files, reports, correspondence, presentations, etc.
• Strong administrative, office, and organizational skills, with attention to detail and ability to manage time and priorities.
• Excellent verbal and written communication and personal interaction skills, with an emphasis on customer service and support.
• Proficiency with Microsoft applications, including Word, Excel, and Outlook; experience with electronic recording keeping and scheduling software (Avatar preferred).
• Ability to develop and maintain strong professional relationships with team members at all levels, clients, including children and adults, and with varying educational, ethnic, professional and economic backgrounds.
• Knowledge of HIPAA requirements that pertain to client information and client privacy.
• Ability to work effectively with minimal supervision, manage multiple duties and priorities, and maintain high standards for accuracy, productivity, and confidentiality.
• Demonstrated flexibility, with ability to work effectively supporting a number of treatment teams.
• Ability to effectively present information and respond to questions from managers, clients, customers, and the general public.
• Ability to function as a member of a team, leading within the scope of the position and contributing whenever possible.

PHYSICAL DEMANDS

To successfully perform the essential duties of this position, an individual must be able to sit at a desk for four or more hours a day, and use office equipment, including phones and computer keyboards, for four or more hours per day. Individuals must be able to engage over the phone and in-person by voice. Regular attendance is an essential function of the position. Reasonable accommodations may be made to assist individuals with disabilities to perform essential position functions.

LIMITATIONS AND DISCLAIMER 

The above position description is meant to describe the general nature and level of work performed; it is not intended as an exhaustive list of all duties, responsibilities and required skills for the position. Team members will be required to follow any other position-related instructions and to perform other duties requested by their supervisor in compliance with Federal and State laws. Requirements are representative of minimum levels of knowledge, skills and/or abilities necessary to perform each duty proficiently. Continued employment remains on an “at-will” basis.

Sign-on bonus and pay range listed are for external applicants ONLY. For questions in regards to internal applicants, please reach out directly to the Recruitment Team.