Credentialing Representative Job Description
Credentialing Representative Duties & Responsibilities
To write an effective credentialing representative job description, begin by listing detailed duties, responsibilities and expectations. We have included credentialing representative job description templates that you can modify and use.
Sample responsibilities for this position include:
Credentialing Representative Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Credentialing Representative
List any licenses or certifications required by the position: GLBA, FCRA, CPCS, DPPA
Education for Credentialing Representative
Typically a job would require a certain level of education.
Employers hiring for the credentialing representative job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Associates, Education, Healthcare, Pharmacy, Management, Business/Administration, Business, Health Care Management, Finance, Health Care
Skills for Credentialing Representative
Desired skills for credentialing representative include:
Desired experience for credentialing representative includes:
Credentialing Representative Examples
Credentialing Representative Job Description
- Making this kind of impact is no easy task
- Credentialing of physical health providers and hospital privileging processes
- Responsible for credentialing of physicians, allied health and other providers/practitioners
- Review and research practitioner data, including both routine and exception credentialing and re-credentialing files, applying established decision matrix criteria when appropriate and effectively communicate exception findings as appropriate
- Handle highly sensitive and confidential information regarding the practitioner networks and the credentialing/re-credentialing processes
- Obtain updated practitioner information, as needed, from various sources
- Inform/Educate practitioners and credentialing contact personnel of the submission requirements for the credentialing/re-credentialing process, stressing the importance of compliance with the processes
- Performs accurate data entry of all practitioner/provider application data into the credentialing database and the document management database
- Resolve any issues that arise with internal and external customers
- Demonstrate great depth of knowledge/skills in own function and act as a technical resource to other
- Knowledge of credentialing procedures, policies, and terminology (e.g., NCQA
- Requires up to 25% local San Diego travel to provider sites
- Previous experience in managed care credentialing preferred
- 3 - 5 years’ experience in human resources or technical credentialing administrative role required
- Familiar with credentialing processes and certification boards
- Job requires approximately 10% travel
Credentialing Representative Job Description
- Develop and oversee management of new and current internally created Processor Control Numbers and pre / post edits
- Monitor, respond and ensure emails submitted to the Managed Care distribution email are addressed timely
- Assist in monitoring and responding to Managed Care Trouble Tickets
- Researching low cost claims, claims with reimbursement issues, claims that are requested to be rebilled
- Assist in admin - rebills when necessary and approved by claim analysis supervisor
- Successfully resolving reimbursement issues and communicating resolution
- Maintain third - party contract database
- Download, save and distribute Managed Care reports
- Monitor plan, network and payer changes
- Basic understanding of third - party contracts and payers
- Experience with Microsoft Word, Excel and PowerPoint with the ability to edit, create, save and send spreadsheets and documents
- 5 years healthcare experience in an administrative role in a health system
- College degree in business, communications or health care administration preferred
- Experience in physician credentialing, enrollment and as a liaison with professional clients in the medical field
- High School Diploma / GED (or higher) or equivalent experience
- 1+ year of experience working with Microsoft Word (opening letters and entering information into fields, data entry) and MS Excel (opening documents, searching, sorting and capturing print screen data template data entry) and Adobe Acrobat (edit docs, merge docs, pdf conversion)
Credentialing Representative Job Description
- Communicate claim issues, reimbursement changes or issues with appropriate account manager
- Maintain understanding of NCPDP and NPPES
- Monitor plan updates and changes
- Analyze, rejected claim report and communicate necessary information on rejected claims by specific plan, network or contract
- Maintain an understanding of Avella drug mix by pharmacy specifically specialty drugs and limited distribution drugs
- Ensure and aid in communicating pharmacy issues related to contract are resolved timely and work closely with client to prevent future issues
- Communicate reports, results, and proposals to internal executive staff
- Maintain 100% accuracy of switching services including but not limited to internal Processor Control Numbers and pre / post edit
- Process provider applications including mailing, reviewing against established criteria, primary source verifications, and loading into the SharePoint and database tracking systems
- Notify providers of the credentialing review process outcomes, including options for reconsideration
- 1+ year of Health Care Provider or Home and Community Based Services Credentialing experience
- 1 year experience in credentialing environment or in the health/managed care industry
- Working knowledge and proficient in all Microsoft Office programs
- Ability to deal with a diverse and challenging provider population
- Ability to respond professionally when dealing with confrontational individuals and situations
- Ability to work independently and to interact with all members of the credentialing team, both internal and external customers
Credentialing Representative Job Description
- Perform outreach via phone, fax and e-mail to obtain missing information needed to complete provider credentialing files
- Track the status of receivables
- Manage accounts payable and accounts receivable operations in compliance with company policies and procedures as assigned by a direct supervisor
- Manage outstanding AP/AR issues
- Prepare complex reports for management review on a routine basis
- Mentor other staff by providing guidance and leadership with the assigned function(s) as applicable
- Submits requests for all Medical Staff and Advanced Practice Provider applications
- Assesses applications for completeness
- Produce verification letters and evaluates if further investigation or information is necessary and makes appropriate inquiries
- Works closely with practitioners and clinical department personnel to ensure that all applications are completed correctly and processed in a timely manner
- Ability to meet or exceed productivity standards established by management
- Ability to work on a regular and timely basis which may require working irregular hours, holidays, and/or weekend
- Strong interpersonal skills, the ability to multi-task, excellent organizational and planning skills, Excellent written and verbal communication skills and display a professional demeanor
- Intermediate level of proficiency with MS Excel (working in spreadsheets) and Word (create and edit documents)Preferred Qualifications
- Associates Degree (or higher) or equivalent of a minimum of 5 years’ experience in an equivalent full - time pharmacy or customer service related role
- Licensed Pharmacist or Certified Pharmacy Technician
Credentialing Representative Job Description
- Responsible for monitoring expirables
- Responsible for managing all outside requests for practitioner hospital/facility verifications
- Perform specific functions pertaining to the Medical Staff credentialing process as assigned
- Assists in creating specialized reports and answers phones
- Maintains filing (paper and electronic) on a consistent time schedule to ensure compliance with department process and regulatory standards
- Maintains necessary knowledge regarding Optum policies, credentialing principles, regulatory/legal standards
- Must have the ability to independently assist practitioners with credentialing and privileging process and questions
- Manage protected information in a secure and confidential manner
- Establish and maintain rapport with internal and external customers
- Coordinates materials for monthly Credentials Committee Meetings and other meetings related to credentialing and privileging processes
- Basic understanding of pharmacy claims processing workflow, pharmacy management system, switching service and Pharmacy Benefit Manager processes
- Skilled in Microsoft Excel on a basic level (ability to set up spreadsheets, sort and filter data)
- Extensive knowledge and understanding of carrier codes and how they function within the pharmacy software system
- Knowledge of managed care and specialty pharmacy industry and experience with client relationship building, negotiations, and budget management
- Demonstrate ability to develop and manage relationships with management, co-workers and all Avella staff specifically related to pharmacy operations
- Skilled in critical thinking, strong verbal and written communication, including presentation skills that is effective with all levels of management, teams, clients, and vendors