Provider Credentialing Specialist

Description

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Position Summary:

The Provider Credentialing Specialist develops and maintains a network of high quality and culturally competent service providers to meet members’ needs through the establishment of service provider contracts, ensuring contracted providers maintain compliance with all required regulations applicable to the contracted service(s). This position monitors providers’ credentials, licenses, negotiates rates, finalizes contracts, and compliance with Lakeland Care provider selection and retention policies. The Provider Credentialing Specialist creates, develops, monitors, and maintains provider electronic records needed to substantiate credentialing and contract compliance.  

Responsibilities & Competencies:

• Complete credentialing and re-credentialing applications, including conducting follow-up with providers to ensure all required documentation is received.
• Compile and maintain current, accurate data for all current and incoming providers.
• Collaborate with providers in LCI’s Contracting and Certification processes.
• Negotiate provider reimbursement in accordance with the LCI rate bands. 
• Monitor timelines for renewal of required documents and collaborate with contracted providers to ensure that compliance with requirements and subsequent eligibility to provide services do not lapse.
• Support providers with basic questions on understanding and interpreting terms of the Lakeland Care service provider contract.
• Provide education to contracted providers regarding the Family Care program and state statutes. 
• Participation in External Quality Review (EQR) Process. 

Requirements

• Bachelor’s degree in a human service field, business related field, or equivalent combination of education and experience (includes knowledge, skills, and abilities). Experience working with the population(s) served in the Family Care program preferred. 
• Experience in provider credentialing in a health insurance and/or managed care environment is preferred. Knowledge of health care/long-term care service provider industry, subcontracting, and licensing and regulatory systems is preferred. Knowledge of network provider contracting in a managed long-term care model is preferred.
• Exceptional organizational skills, accuracy, and precision in record-keeping activities are required.
• Strong communication, determination, and ability to motivate others are necessary. 
• Current driver’s license, acceptable driving record and proof of adequate insurance required. 

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Lakeland Care is a Wisconsin-based non-profit organization that focuses on creating a world we all want to live in. With long-standing roots as a managed care organization (MCO), Lakeland Care provides long-term care services and supports to eligible frail elders and individuals with physical and intellectual or developmental disabilities to achieve their daily and lifelong goals through Wisconsin’s Family Care program. Currently we serve in 22 counties and have 10 offices in the Central to North East region of Wisconsin.

Our Mission

Empowering individuals. Strengthening communities. Inspiring futures.

Our Vision

To create a world we all want to live in.

Our Core Values

Kindness – We believe kindness is always possible and that no compassionate act is ever wasted.

Inclusion – We believe that open hearts and open minds are the only path to a brighter future.

Trust – We believe that honesty is still in style and that promises still have power.

We are an equal employment opportunity employer functioning under an Affirmative Action Plan. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law. We are an organization that participates in E-Verify.