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Credentialing Specialist

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily / weekly production goals and maintaining a high level of confidentiality for provider information.

Job Duties :

• Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies / procedures and regulatory requirements, while meeting production goals.
• Communicates with health care providers to clarify questions and request any missing information.
• Updates credentialing software systems with required information.
• Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.
• Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
• Completes data corrections in the credentialing database necessary for processing of recredentialing applications.
• Reviews claims payment systems to determine provider status, as necessary.
• Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.
• Reviews and processes daily alerts for federal / state and license sanctions and exclusions reports to determine if providers have sanctions / exclusions.
• Reviews and processes daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare.
• Reviews and processes daily NPDB Continuous Query reports and takes appropriate action when new reports are found.

Job Qualifications :

Required Education : High School Diploma or GED.

Required Experience / Knowledge Skills & Abilities :

Preferred Experience :

Experience in the health care industry

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V Pay Range : $21.16 - $34.88 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.