Provider Credentialing Specialist

TriWest Healthcare AlliancePhoenix, AZ

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Job Summary

The Provider Credentialing Specialist supports the Credentialing Department by managing and maintaining accurate, up-to-date provider data to include updates, changes, additions and terminations in the credentialing, while working under timeline, accuracy and production targets. Performs credentialing activities including primary source verifications, communicating with Providers to request missing information supporting the integrity of Provider data in all downstream systems, and key-entering initial data of potential network Providers into the credentialing system.

Education & Experience

Required :

High School Diploma or GED
If supporting TRICARE contract, must be a U.S. Citizen
If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
6 months or more of provider credentialing experience

Preferred :

1+ years of credentialing experience

Experience using provider credentialing software systems or Provider Data Management Systems

Knowledge of URAC or NCQA standards

Key Responsibilities

Process Provider credentialing inventory within expected timeline, accuracy and production targets.

Update outdated provider credentialing and demographic information.

Reviews Provider applications and verifies that each meets all credentialing criteria.

Reviews Provider applications for accuracy and completeness and follows-up to obtain missing information materials in a timely manner and in accordance with department standards.

Queries primary sources, as applicable, to verify Provider credentials and qualifications.

Prepares files for review by the Credentialing Committee.

Maintains current credentialing, directory status information in a Provider credentialing system (Provider database).

Represents the Credentialing Unit at Credentialing Committee meetings as needed.

Achieves and maintains required department credentialing timeframe standards.

Communicates, though both written and verbal communication, in a professional and concise manner and is able to share information and / or instructions for updating and correcting Provider credentialing databases.

Coordinate with internal departments for Provider database related issues.

Works with Credentialing Verification Organization(s) as directed.

Performs other duties as assigned.

Regular and reliable attendance is required.

Competencies

Commitment to Task : Ability to conform to established policies and procedures; exhibit high motivation.

Communication / People Skills : Ability to influence or persuade others under positive or negative circumstances; adapt to unique styles; listen critically; collaborate.

Computer Literacy : Ability to function in a multi-system Microsoft environment using Word, Excel, Outlook, TriWest Intranet, the Internet, and department software applications.

Organizational Skills : Detail-oriented with the ability to organize people or tasks, adjust priorities, learn systems, within time constraints and with available resources.

Problem Solving / Analysis : Able to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Technical Skills : Proficient with key databases, including credentialing software systems, Provider Data Management Systems, and Provider Information Management Systems; working knowledge of Provider credentialing policies and procedures, healthcare or managed care experience

Working Conditions

Working Conditions :

Availability to cover any work shift

Works within a standard office environment, with minimal travel

Extensive computer work with prolonged periods of sitting

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Credentialing Specialist • Phoenix, AZ