Job Description

Credentialing Specialist

This role will credential practitioners for network participation with CareFirst BlueCross BlueShield and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.

Essential Functions:

• Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the CareFirst networks.
• Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, contractual status and provider file updates.
• Maintains the provider file, PDMES inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities.
• Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

Qualifications:

• Education Level: High School Diploma or GED.
• Experience: 3 years physician credentialing experience or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.
• Preferred Qualifications: Bachelors Degree in Business, Healthcare Administration or related field.

Knowledge, Skills and Abilities (KSAs):

• Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables.
• Excellent verbal and written communication and interpersonal skills.
• Knowledge of medical terminology.
• Demonstrated proficiency utilizing reference materials and ability to follow Standard Operating procedures to reduce risk and ensure provider data accuracy and overall quality.
• Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes and interpret reasoning for performing verification and/or appropriate actions.

Licenses/Certifications: Certified Provider Credentialing Specialist (CPCS) Preferred

Salary Range: $38,520 - $70,620

Department: Core Consolidation Government

Equal Employment Opportunity: CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Physical Demands: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US: Must be eligible to work in the U.S. without Sponsorship.

Requisition Number: 21280

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