Provider Enrollment & Credentialing Specialist

Provider Enrollment and Credentialing Specialist reviews all aspects of the Initial/ Re-Apply Credentialing, Re-credentialing, privileging and overseeing the onboarding process for all incoming providers. Primary responsibilities include verifying all the credentialing criteria for practitioners that have applied to the network, including follow up with practitioners as needed to obtain information.

PRIMARY JOB RESPONSIBILITIES:

• Verify potential and existing providers licensure, NPI, insurance, CDS, DEA certificate, education, hospital privileges, board certification.
• Review National Practitioners Data Bank for adverse charges pending or filed against Provider.
• Review federal and/ or state OIG and SAM report for exclusion from the Medicaid or Medicare program.
• Review state Medicare OPT Out report for exclusion from the Medicare program.
• Monitors and reports provider complaints and utilization management reports.
• Assist with scheduling site reviews. Enroll the provider into payment system Windward.
• Enter all provider information into credentialing database Cactus. Maintain the integrity of the provider information in Windward and Cactus.
• Ensures credentialing file is in order with any issues flagged for committee.
• Meet required turnaround time and accuracy rate.
• Assist with other duties as assigned.
• Assist management in the implementation of department process improvements.
• Assist with the ongoing NCQA certification activities.
• Represent DentaQuest in a professional manner at all times while communicating with internal and external requestors.
• Maintains confidentiality of the credentialing information.
• Other duties as needed or required.

JOB QUALIFICATIONS:

Required:

• High School Diploma or equivalent.
• 1 year job related experience Good interpersonal skills.
• Ability to work independently.
• Excellent oral and written communication skills.
• Efficient PC skills (Word, Excel, Outlook, Work Flow Software, Time Tracking Systems).
• Ability to learn new software programs quickly.
• Ability to prioritize and organize multiple tasks.
• Ability to remain organized with multiple interruptions.
• Good customer service and problem resolution skills.
• Ability to navigate websites needed for credentialing purposes.
• Ability to adapt to a constantly changing environment.
• Ability to work in excess of 40 hours in a week.
• Required to attend additional training as requested/deemed necessary.

Preferred:

• Previous experience working with files or the collection and coordination of data preferred.
• Knowledge of Dental terminology preferred.

PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.