Credentialing Specialist

Overview
Join our dynamic Outpatient Pediatric Theapy team as a Credentialing Specialist, where your expertise will ensure the seamless verification and maintenance of provider credentials in compliance with industry standards. In this vital role, you will manage the credentialing process for our providers, ensuring they meet all regulatory and organizational requirements to deliver quality care. Your proactive approach and attention to detail will contribute directly to our mission of providing exceptional patient services while maintaining adherence to managed care policies and NCQA (National Committee for Quality Assurance) standards.

Duties

• Review and verify provider credentials, licenses, certifications, and educational backgrounds to ensure accuracy and completeness.
• Coordinate with providers, licensing boards, and other entities to obtain necessary documentation for credentialing and re-credentialing processes.
• Maintain up-to-date records in compliance with NCQA standards and managed care requirements, ensuring timely renewals and updates.
• Facilitate communication between providers, insurance companies, and internal teams to resolve credentialing issues efficiently.
• Prepare detailed reports on credentialing status, audit trails, and compliance metrics for internal review and regulatory audits.
• Support Audit and Quality Assurance efforts related to provider credentialing files.
• Maintain confidentiality of all sensitive provider and patient information in compliance with HIPAA regulations.
• Stay informed about changes in healthcare regulations, managed care policies, and industry best practices to ensure ongoing compliance.

Requirements

• Preferred: Experience in medical office administration or healthcare credentialing processes.
• Preferred: Knowledge of Medicaid, SoonerSelect Managed Care Plans, and commercial insurance.
• Preferred: Knowledge of medical terminology to accurately interpret provider credentials and documentation.
• Preferred: Familiarity with NCQA standards and accreditation requirements related to provider credentialing.
• Preferred: Familiarity with CAQH, NPPES, and Payor Specific Portals
• Preferred: Familiarity with Pediatric Therapy Services: OT, PT, Speech, and ABA Services
• Required: Microsoft Office, Excel, Outlook
• Required: Excellent organizational skills with the ability to manage multiple tasks efficiently under tight deadlines.
• Required: Exceptional attention to detail to prevent errors that could impact provider eligibility or compliance status.
• Required: Effective communication skills for liaising with therapy providers, insurance representatives, and internal teams.
• Required: Self-Motivated, Results Driven with the ability to work independently.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential job functions of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the job. While performing the duties of this role, the employee is frequently required to stand, sit, walk, communicate, and hear. The employee is also required to frequently to use hands, fingers, and arms to feel, handle, or reach. Vision abilities required by this position include close vision, distance vision, and ability to adjust focus. This position may also expose the employee to clients displaying socially undesirable behaviors.

AAP/EEO Statement

Soaring on Hope does not discriminate in employment with regard to race, creed, national origin, political affiliation, marital status, age, gender, sexual orientation, or number of dependents. As part of the Soaring on Hope team, no provider or staff shall aid, coerce, or conspire to cause a termination or resignation of another staff because of illegal discriminatory factors.

Please note this job description is not an exhaustive list of activities, duties, or responsibilities that are required of the employee for this job. Duties, activities, and responsibilities may change at any time with or without notice.

Job Type: Full-time

Pay: $ $25.00 per hour

Expected hours: 35 – 40 per week

Benefits:

• 401(k)
• 401(k) matching
• AD&D insurance
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending