Credentialing and Enrollment Specialist

You Will Focus On:

• Responsible for all aspects of credentialing/recredentialing providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, and accurately loading provider information in the Credentialing database (CAQH, Availty, etc.) & maintaining accurate information in the provider tracking logs (excel).
• Responsible for processing credentialing/recredentialing applications accurately and promptly in accordance with Altais Medical Group policies and procedures, health plan delegation requirements and NCQA standards. To include credentialing for health plans, hospital medical staff and surgery centers.
• Responsible for communicating provider changes to contracted health plans and Altais Medical Group management via standardized report(s).
• Continuous monitoring of payor enrollment to ensure accuracy of all provider information.
• Works with payors to facilitate issue resolution, re-enrollment, and termination requirements.
• Coordinates responses to inquiries regarding payor’s inquiries; follows up with each payor and or provider to completion; assesses provider credentialing files to determine if additional information is required; revisits state and federal bulletins for provider sanctions.
• Responsible for accurate input and modifications to the credentialing database, which includes performing audits to assure accuracy.
• Coordinate credentialing and re-credentialing processes, maintaining task grids and tickler systems to assure follow up and completion. Maintain communication with Medical Services and Care Management Departments, to ensure review processes are completed in a timely manner.
• Prepare materials and files necessary to comply with external audits by payors and/or governmental agencies. Maintain ongoing communication with health plan representatives and Altais Medical Group department leaders.
• Proactively verify enrollment of all providers in health plans and rectify any issues in a timely manner.
• Disseminate new/modified professional information to Altais Medical Group providers and departments.
• Facilitate annual employee health requirements for providers.
• Facilitate applications for online processing of EDD claims.

The Skills & Experience You Bring:

• Excellent computer skills including Microsoft Office (Word, Outlook, Excel, PowerPoint).
• Use independent judgment and initiative within established policies and procedures.
• Ability to Interact and maintain excellent relationships with all levels of staff and management and external contacts to support compliance and high levels of service.
• Excellent communication skills, both written and verbal.
• Excellent organizational skills.
• Ability to obtain, synthesize and analyze data and recommend solutions.
• Ability to work on multiple projects concurrently.
• Ability to draft materials, including presentations, handouts, and communications.
• Possesses a learning and growth mindset, creative thinker.
• High School Degree or GED; Bachelor's Degree preferred
• 3+ years of Health Plan/Medical Group experience with preferred experience with an IPA