Provider Relations Credentialing

Job Summary:

As a Credentialing Representative, your primary responsibility is to oversee and manage the credentialing process within CLC’s organization. You will be maintaining all provider files (attorney and mediators), contracted and non-contracted in accordance with company policy, and maintaining contact and responding to provider inquiries. Your attention to detail and adherence to regulatory guidelines will play a crucial role in maintaining compliance and upholding the organization's reputation.

Responsibilities:

Scope of the Role

Under minimal supervision, you will be responsible for collecting and reviewing credential applications, verifying the accuracy and completeness of the information provided. You will validate the licensing of network providers through local and state agencies to confirm that providers meet the required standards.

Continuous quality assurance and performance improvement are important aspects of the role. You will participate in quality assurance activities related to credentialing and identify opportunities for process enhancements. Regular audits and quality checks will be conducted to ensure the accuracy and integrity of data.

Credential representative supports the company’s mission to provide high-quality customer service to members, providers, and potential customers. This includes outbound calling, receiving inbound calls, and email communications to providers.

Performance Outcomes

Credentialing Process Management

• Collect and review credential applications for completeness and accuracy.

• Ensure all required documents, such as education, training, licensure, and certifications, are obtained and verified.

• Maintain a thorough understanding of regulatory requirements, accrediting standards, and internal policies related to credentialing.

• Manage the initial and re-credentialing processes for all network providers.

• Keep track of deadlines and ensure timely completion of the credentialing process.

Verification and Evaluation

• Verify the credentials for the accuracy of information provided by network providers including education, training, certifications, and licenses, through primary sources.

• Conducting thorough background to local state bar agencies.

• Evaluate network healthcare provider credentials to ensure they meet the required standards and qualifications.

• Assess and address any discrepancies or issues that arise during the credential process.

• Document and maintain records of verification outcomes.

Compliance and Database Management

• Ensure compliance with applicable regulatory requirements and accrediting standards.

• Stay updated with changes in regulations and standards and make necessary adjustments to the credentialing process.

• Maintain accurate and up-to-date records of network providers in a credential database. d. Enter and update information related to credentials, licenses, certifications, and other relevant details.

• Generate reports on credentialing status, expirations, and upcoming re-credentialing activities.

• Collaborate with internal and external stakeholders to address and resolve any compliance issues.

Education, Knowledge, and Experience

• 3 years of experience in customer service, preferably in sales environment preferred

• High School diploma or equivalent required

• Strong computer knowledge; proficiency in Microsoft Office applications

• Types a minimum of 35 WPM

• Compassionate, courteous, and concise communication skills

• Excellent writing skills

• Ability to educate our customers effectively and accurately on products and services

• Excellent telephone etiquette

• Detail-oriented and strong organizational skills

• Strong computer knowledge; proficiency in Microsoft Office applications

• Ability to multi-task with multiple assigned contracts

• Accurately able to retain and document copious amounts of information

FLSA Status

Non Exempt

Physical Requirements/ Work Environment

The work environment characteristics and physical demands described here are representative of these 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.

• Maintain excellent attendance and adherence

• Able to retain copious amounts of information as it relates to the customer’s issue, the customer's benefits, and limitations.

• Prolonged periods of sitting or standing at a desk and working on a computer.

• Must be able to regularly lift and carry and otherwise move up to 15 pounds at times and occasionally up to 30 pounds.

• The ability to frequently physically move between departments/floors.

• While performing the duties of this job, the employee is regularly required to use hands free and fingers to handle, feel, or operate objects, tools, or controls, and reach with hands and arms.

Additional Information:

Location: Remote – United States

Work Arrangement: This…