Credentialing Specialist II

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Credentialing Specialist II is responsible for all activities associated with the physician credentialing and recredentialing process and the maintenance of Capital Blue Cross and provider files for all lines of business. The position is responsible for the review and processing of provider applications for submission to the Credentialing Committee for approval, processing of Delegated Credentialing verification files from Capital's delegated credentialing entities, and QCing of the credentialing files after processing by other Credentialing Specialists. The Credentialing Specialist II is required to interface and coordinate activities with other Capital departments such as Provider Management and Provider Operations to ensure timely completion of credentialing activities. The Credentialing Specialist is responsible for maintaining the integrity of provider data in the credentialing database. This position requires a thorough knowledge of NCQA regulations, Capital's Credentialing Policies and Procedures, as well as physician profile mechanisms in order to assure compliance with NCQA Regulations. Workflow management abilities are essential. The incumbent will provide direct assistance to the credentialing manager as needed.

Responsibilities and Qualifications

• Credentialing and Recredentialing Process: Process credentialing/recredentialing applications in a timely manner and meet production standards of work unit by volume in accordance with the prevailing credentialing unit production timelines. Be able to transition between processing initial credentialing and recredentialing applications when the manager requests. Process all credentialing/recredentialing applications with a 98% accuracy rate. QC the processed credentialing files against NCQA, CMS and DOH regulations resulting in error reports on a monthly basis. Analyze application materials to assure that providers meet NCQA, CMS and Plan criteria and, as appropriate, obtain verification information from external sources such as the State Board of Licensure, appropriate board certification agencies, hospitals, medical schools, the Drug Enforcement Agency, and the National Practitioner Databank. Present to the Manager and and/or Credentialing Coordinator complete and accurate information on a provider that is going to the Pre-Credentialing Committee Meeting as an “issue.” All information must be presented to the Manager and/or Credentialing Coordinator by the Friday before a Pre-Credentialing Meeting Recommend quality improvement to enhance workflow and to increase overall performance and increase efficiencies.
• Data Management, Integrity and Quality: Review the source document/application for complete and accurate information. Maintain integrity of provider data through ongoing monitoring and updates to provider information in the provider credentialing software. Interface with practitioners, office managers, etc. regarding questions or issues with source document information/application.
• Job Knowledge: Maintains an in-depth understanding of NCQA Guidelines. Maintains an in-depth knowledge of how credentialing files are maintained in Cactus. Maintains an in-depth understanding of the different credentialing criteria needed to credential/recredential a provider and assess and reassess a facility.
• Technical and Administrative Support: Facilitate or assist in the assessment and reassessment of facilities. Process DCV files received by delegates entities in a timely manner. Oversee/Perform annual oversight NCQA file audits with delegates’ entities. Build queries in Cactus to create reports as needed. QC completed processed credentialing and recredentialing files. Identify, research, and resolve technical and operation issues. (Including with outside vendors such as Cactus and CAQH). Review and primary source verify all medical licenses and certifications (new and expired licenses and certifications) for employees per Credentialing Policy and Procedures (Monthly). Review and primary source verify all Capital Clinical Staff Employees licenses, DEA and board certification. Review PA, MD and NJ’s Medical Licenses sanctions on a monthly basis. Gather all the needed information on all providers that are participating with Capital and are appearing on the sanction reports and reports sanction information to the Manager for possible presentation to the Credentialing Committee.

Skills:

• Team player, good interpersonal skills, dependable
• Detail oriented, ability to multitask, be able to work independently and as team, demonstrate ability to effectively communicate both verbally and written, demonstrate research and analytical skills, be able to maintain focus for long periods of time. Ability to take direction from and perform project support work for various levels of staff.

Knowledge:

• Working knowledge of Cactus, Facets, Pix Database, Adobe/Nuance, Microsoft Office or similar software

Experience:

• Minimum of three years’ experience in healthcare, preferably in a related area.

Education and Certifications:

• Minimum requirements include high school diploma or GED.

Work Environment:

• Sedentary work involving significant periods of sitting, keying and performing repetitive motions.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Minimal travel required

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