Credentialing Specialist

• Maintain timely and accurate credentialing and re-credentialing of all Independent Health providers
• Manage provider files and documentation in adherence with regulatory requirements and Independent Health policies
• Work with internal departments to ensure provider data accuracy
• Provide effective, professional external customer service
• Maintain all work through the Healthrules system
• Input provider applications into the credentialing database and process within required time frames
• Ensure applications are complete, accurate, and compliant with NCQA, DOH, CMS, and Independent Health policy requirements
• Complete and close clean, routine applications and assigned recredential files within required time frames
• Initiate credentialing packets as assigned and scheduled
• Track processes to maintain compliance with federal, state, NCQA, and internal requirements
• Follow up and take action on conflicting or incomplete information
• Review and edit files for completeness and accuracy before analyst review
• Maintain Network Evaluation process and physician network profiles
• Gather and document information from respective departments for recredentialing review
• Perform primary source verification using credentialing software according to IPA/WNY policies and procedures
• Query primary sources by letter or phone to verify information
• Initiate additional requests when responses are not received within required time frames
• Query databases and internet sources to verify licenses, board information, sanctions, and claims history
• Maintain the credentialing database and provider hard-copy files
• Enter changes and update provider credentialing database records in Cactus and Health Rules
• Remain current and informed on credentialing policies and procedures
• Generate routine and follow-up reports from the system
• Provide the manager with month-end status reports of assigned files