The Credentialing Specialist provides general support to our client’s credentialing process. The Credentialing Specialists primary responsibilities are to credential & re-credential all providers and facilities with agency contracted insurance carriers. The Credentialing Specialist assists in the development of credentialing workflows, process, and policies. The qualified applicant for this position will be familiar with the Oregon credentialing application, NPI, Medicare regulations and Oregon Health Authority. With the high prevalence of trauma among individuals receiving mental health services, it is required the Credentialing Specialist understand the effects of trauma on health, coping, and other aspects of the lives of those we serve.
Credentialing Specialist Responsibilities
Current knowledge of credentialing process in relation to the Oregon Health Plan (OHP), Medicare and commercial insurance.
Verify credentialing degrees of all new employees as related to position specific job requirements.
Maintain tracking system with current credentialing status for all providers/counselors.
Maintain and organize credentialing files.
Provide any necessary follow up regarding the credentialing of new employees.
Ensure eligible staff have NPI numbers and appropriate taxonomy codes to bill for services rendered.
Follow up on credentialing requirements for licensed employees and coordinate with staff and licensing agencies.
Maintain, track and follow up on the Expired Licenses Report on a monthly basis.
Maintain, track and follow up on the Exclusionary Database Report (OIG/SAM) both at the time of NEO as a new hire and ongoing on a monthly basis.
Review regulatory and disciplinary action reports issued by State licensure bodies, Federal agents and the Office of Inspector General Medicaid and Medicare Sanctions report; identify providers that appear in our databases and invoke the appropriate process as defined in policy and procedure.
Work in collaboration with internal stakeholders to ensure credentialing is in compliance with established insurance regulations and agency policies.
Adhere to all state and federal privacy regulations, including HIPAA and 42 CFR Part 2, and to company policies and agreements regarding confidentiality, privacy, and security. Support compliance with all privacy and security requirements pursuant to community partners and outside providers patient confidentiality agreements, including privacy and security requirements for EMR access.
Provide comprehensive coordination and works collaboratively with internal stakeholders as a single point of contact to enroll new providers & facilities in health plans.
Manages & maintains all provider and facility health plan credentialing and re-credentialing applications for accurate, timely billing and encounter reporting.
Ensures company staff and facilities credentials meet government and accrediting agency standards:
a. Licensed & Certified Practitioners
b. Volunteers and Contractors
c. Pharmacy - 340b
Credentials: MD, ND, PA-C, NP, PMHNP, LCSW, PhD, RPH, CADC, QMHA, QMHP, LPC, LPN, RN, EMT, CRM, PSS, CMA CPHT, PL, LaC.
Obtain and maintain NPI's, work with CMS on revalidations audits and provider enrollment through third party payers.
a. NPDB reporting, OIG\SAM, licensure verification, DMAP licenses
b. OIG\SAM (Office of Inspector General\ System for Award Management)
c. National Practitioner Data Bank (NPDB) reporting
d. Annual Federal Tort Claims Act (FTCA) reporting requirements
e. Multnomah County DSN
f. HealthShare Mental Health
Recommend new approaches, policies, and procedures to effect continual improvements in efficiency of department and services performed.
Support and serve as back up to the Human Resource Team.
Complete annual employee training requirements on a timely basis.
Perform other duties as assigned.
Credentialing Specialist Qualifications
High School or GED required. An undergraduate degree from an accredited institution of higher learning preferred. Certified Provider Credentialing Specialist (CPCS) certification is preferred or years of experience may be considered equivalent.
Minimum two years credentialing experience or related health care experience required; or an equivalent combination of education, training, and experience.
Knowledge of Oregon credentialing application, NPI, Medicare regulations and Oregon Health Authority.
Proficiency with MS Office applications.
Operate computer hardware and software at a level needed to effectively perform job functions.
Enter, retrieve, analyze data.
Prepare moderate to complex reports.
Ability to commute to other company locations or community sites.
Benefits are available to eligible VanderHouwen contractors and include coverage for medical, dental, vision, life insurance, short and long term disability, and matching 401k.
VanderHouwen is an award-winning, Women-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen has been successfully placing experienced professionals throughout the Pacific Northwest and nationwide. Our recruitment teams are highly specialized in either Technology and IT, Engineering, or Accounting and Finance career markets. Our recruiters value building meaningful, professional relationships with each candidate as well as developing honed knowledge of companies' staffing needs and workplaces. Partner with us to land your next exciting career.
VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state or federal civil rights laws.
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