Credentialing Specialist
At UCare, we deliver high-quality health coverage and services to help more than 400,000 members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.
Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other.
The Credentialing Specialist is responsible for the credentialing and recredentialing processes per NCQA, CMS and MDH Standards for all contracted providers. The application process includes maintenance of the online application site and forms repository and intake, review and appropriate routing of credentialing documents. Collaborate with both internal and external agencies involved in the credentialing process.
DUTIES AND RESPONSIBILITIES:
Analyze practitioner and facility credentialing applications to determine eligibility status as defined in UCare's Credentialing Plan.
Assist in development and implementation of credentialing policies and procedures.
Perform primary source verification for initial and recredentialing of assigned providers utilizing NCQA Standards and other federal and state regulatory requirements. Ensure timely verification to prevent any negative impact related to compliance or regulatory requirements.
Maintain timely communication with external providers regarding the eligibility and credentialing decisions and/or related provider issues.
Serve as resource specialist for internal departments for daily issues related to provider credentialing actitivites.
Collaborate with manager, as necessary, regarding credentialing and recredentialing applications that require additional investigation due to concerns related to professional criteria.
Enter and maintain credentialing data following NCQA as well as state and federal requirements.
Qualifications:
High school graduate or equivalent. Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator Certification strongly desired.
Two years experience in health care related environment, preferably in an insurance or HMO environment with exposure and familiarity with the process for providers is required. PC experience including spreadsheet, and word processing, preferably Microsoft Access, Excel and Word is also required. Experience in a clinic business office, insurance or HMO environment is preferred. Delegation of credentialing/recredentialing and/or credentialing/recredentialing experience is highly desired.
Please apply at