Credentialing Specialist

DEPARTMENT: Operations ## RATE: $21.00 per hour, with potential for additional compensation based on qualifications. ## POSITION SUMMARY: The credentialing specialist performs confidential Upper Peninsula Health Plan (UPHP) credentialing and office duties and interfaces with UPHP staff, providers, and provider offices on a daily basis. ## ESSENTIAL DUTIES AND RESPONSIBILITIES: 1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information. 2. Completes Credentialing Verification Organization (CVO) duties which includes research, obtaining verifications, recognizing and investigating discrepancies in information, and compiling data for review. 3. Follows established UPHP policies, procedures, and objectives to ensure provider credentialing is in compliance with all licensing standards and accrediting and regulating organizations, i.e., National Committee for Quality Assurance (NCQA), The Joint Commission (JC), the Michigan Department of Health and Human Services (MDHHS), Center for Medicare and Medicaid Services (CMS), and the Michigan Department of Insurance and Financial Services (DIFS). 4. Processes applications for provider membership and reappointment in accordance with the UPHP credentialing policies. 5. Maintains current information in the credentialing database; communicates via telephone, fax, and email with physicians and their key staff regarding currency of credentialing files. 6. Maintains accuracy and confidentiality of UPHP credentialing database and participates in an annual audit of the database. 7. Compiles credentialing status reports as necessary for CVO clients, internal UPHP departments, and senior management. 8. Responsible for maintaining all applicable updates of licenses, insurance, and board certification of UPHP and CVO client providers. 9. Reviews sanction databases and performs ongoing monitoring to ensure provider compliance. 10. Responds quickly, courteously, and accurately to all provider status inquiries maintaining confidence and reliability to providers and clients. 11. Performs other related duties as assigned or requested. ## POSITION QUALIFICATIONS: ### Education: #### Minimum: Two (2) years post-secondary education or combination of education and experience #### Preferred: Associate or bachelor's degree in business, health information processing, health information systems, or related field ### Experience: #### Minimum: Two (2) years progressive office experience #### Preferred: One (1) year of credentialing experience #### Required Skills: Working knowledge of MS Office (Word, Excel, and PowerPoint) Keyboarding proficiency Excellent human relation and oral/written communication Excellent organizational and prioritization abilities with attention to detail The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria. #### #### Physical Requirements: [This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirem