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Credentialing Specialists are responsible for verifying the professional licenses and certifications of medical staff. Their duty is making sure that federal and state standards are met and they may also assist auditors and help keeping a facility's accreditation. The strongest example resumes for Credentialing Specialists emphasize health information expertise, organization, attention to details, teamwork and communication skills. Report writing skills are a must. Most sample resumes for Credentialing Specialists highlight an Associate's Degree in health information management.

For more information on what it takes to be a Credentialing Specialist, check out our complete Credentialing Specialist Job Description.

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31

Credentialing Specialist

  • Performs initial and re-credentialing activities to assure each application met credentialing standards.
  • Receives, researches and answers calls from provider offices regarding credentialing and other quality issues.
  • Communicates daily with physicians and hospital medical personnel to obtain needed documentation for provider files; completes written correspondence and maintains organized files.
  • Assists with preparing for monthly MAC by auditing files, pulling spec sheets, assembling binders and updating Cactus.
  • Understands the use of Cactus, Word, Excel, and CareVu Systems
  • Maintains all Credentialing turnaround times.
Candidate Info
7
years in
workforce
3
years
at this job
HS
High School Diploma
32

Credentialing Specialist

  • Manage credentialing with third party contracts focusing on quality assurance and regulatory compliance.
  • Analyze and identify discrepancies in the credentialing process and redevelop new policies and procedures to create a more consistent workflow in the department.
  • Create and manage tracking tools to maintain workflow in the department, and provide recommendations and insights to executive leadership to justify workload and hiring additional staff.
  • Process credentialing and re-credentialing application and/or enrollments of healthcare providers in a timely manner consistent with internal policies and procedures while meeting funder requirements.
  • Review provider applications, prepare verification letters, and maintains database with accurate, up-to-date information.
  • Responsible for collecting, entering, updating and maintaining NPI, CAQH, AHCCCS, Medicare and any other applicable provider numbers and information in the system.
  • Responsible for communicating with medical office staff, licensing agencies, and insurance carriers/health plans on a regular basis, developing relationships benefiting the agency.
Candidate Info
6
years in
workforce
9
months
at this job
BS
Healthcare Administration
33

Billing/credentialing Specialist/ Payment Posting

Service external and internal customers with exceptional customer service

  • Handle and maintain front and back office
  • Verify patient insurance effectiveness
  • Credential new and existing providers for network participation
  • Patient Charting
  • Review claims payment accuracy.
  • Insurance/ Payment Posting
Candidate Info
16
years in
workforce
14
years
at this job
AS
Associate of Science
BS
Bachelor of Science
34

Credentialing Specialist

  • Performed quality audits on and maintain practitioner profiles ensuring they are ready for Credentialing committee in accordance with office policy, Joint Commission standards, and State and Federal Regulatory guidelines.
  • Quality audit review includes but is not limited to: review of all primary source verifications, all online verifications to include EPLS, OIG, NPI, NPDB, DEA, State Licenses, CDS, and ECFMG.
  • Assist in the credentialing process by entering/logging/scanning information into credentialing system for initial, updated, add on applications and maintenance processes.
  • Acts as liaison with MSO as point person for completing and ensuring compliance and delivery of required information to clients in a timely manner.
  • Mentor probationary employees for various teams to ensure they were performing appropriately.
Candidate Info
16
years in
workforce
7
years
at this job
BA
Sociology / Criminal Justice
35

Credentialing Specialist

Track and manage compliance based on JCAHO (Joint Commission on Accreditation of Healthcare Organization) policies and procedures implemented by the company

  • Prepare credentialing and re-credentialing applications on behalf of physicians and Nurse
  • Credentialing files to meet VMS standards
  • Conduct monthly audits for file compliance report to JCAHO
  • Interface with contacts from client facilities/hospitals on compliance requirements and updates
  • Set up and monitor all background checks and drug screens
  • Distribute and maintain all competency testing for candidates
  • Obtain all required documents for facility specific on-boarding requirements
  • Verify all professional licenses and certifications for all candidates
  • Candidate submittal review for facility placement
  • Ensuring all candidate files are compliant by pulling weekly reports to ensure all documents remain current
Candidate Info
16
years in
workforce
4
years
at this job
Medical Billing
36

Credentialing Specialist/ Coordinator

Provide credentialing and privileging verifications, including all Peer References, Education, and Affiliations. Participate in the delegated credentialing audit process as needed

  • Manage monthly Expired Credentials and Expiring Facility Privileges to ensure timely renewals.
  • Validate and process acceptable documents such as medical records, background check results and certifications.
  • Processing, auditing and review of credentialing and re-credentialing of allied Health providers.
  • Building/maintaining relationships with field/branch employees
  • Accurate completion of employee files including pre-employment screenings, credentialing, and testing
  • Managing compliance in accordance with Joint Commission and MSN standards
  • Working with existing field/branch employees to keep documents current, active and compliant.
  • Providing back-up support (with additional functions as deemed required) to help assure all operational needs are met
Candidate Info
5
years in
workforce
7
months
at this job
AS
Health Management
37

Credentialing Specialist, Medical Billing

Timely and accurate data verification, electronic transactions, pay-to-address, commercial and state insurance enrollment

  • Ability to maintain and monitor assigned client accounts and respond to client questions and changes regarding enrollment related issues
  • Working cross-functionally to continuously improve our service
  • Participate in client calls as needed. Evaluate enrollment requirements for new and prospective clients
  • Coordination and project management of the enrollment portion of client implementations when needed to ensure all enrollment deadlines are met or surpassed
  • Review claim notes, conduct supplemental research and analysis, and process large amounts of information in order to take appropriate next actions on claims
  • Review payments and/or denials posted, Research and understand payor and posting issues, Identify, document, and communicate existing and potential problems
  • Compile information regarding errors, complete reports on a weekly, monthly basis, resolve unpostable items
  • Document client and product-specific posting procedures to ensure internal staff and vendor are provided with required training materials
  • Cross functional investigation and resolution of enrollment related claim denials
Candidate Info
19
years in
workforce
2
years
at this job
38

Credentialing Specialist

Maintain an excellent record of performance in quality assurance and data integrity to ensure accuracy and completeness of provider credentialing process.

  • Responsible for reviewing, researching and primary source verifying provider credentialing and recredentialing practitioner and health delivery organizations to ensure compliance with CFHP policies and procedures, NCQA, and TDI and HHSC guidelines.
  • Oversees the daily activities associated with the efficient operation of the provider credentialing process, in cooperation with the Network Management department, Quality Management department and the Medical Director.
  • Organizes and maintains files, receives incoming and makes outgoing calls to providers to obtain missing or additional information for application completeness.
  • Coordinates and attends the bi-monthly Credentialing Committee meetings. Works in conjunction with the Credentialing Manager in coordinating the credentialing committee activities.
  • Prepares various monthly, quarterly and annual reports relevant to the provider credentialing process and performs other related duties as requested or assigned.
Candidate Info
11
years in
workforce
4
years
at this job
AS
Business Management
BS
Business Administration
39

Provider Enrollment/credentialing Specialist

Provider Enrollment/Credentialing

  • Screen and analyze provider data forms: CMS 855I and CMS 855R (Reassignment of Benefits)
  • Determine whether the applicant meets all requirements/qualifications of Medicare Part B and all applicable state requirements.
  • Send notification of missing information that is needed to properly complete the enrollment process.
  • Research and resolve provider problems and complaints.
  • Maintain above average knowledge of medical practices as it relates to Medicare
  • Organize time and workflow
  • Answer telephone calls from providers and other Medicare Services area that are related to provider enrollment policies and procedures
  • Strive to conduct daily operations in a professional manner, according to the values established by Medicare services operations.
  • Identify fraudulent providers enrolling in the Medicare program.
  • Understanding of Physician's Current Procedural Terminology (CPT) coding for determination of specialty billing.
Candidate Info
10
years in
workforce
1
year
at this job
HS
Medical Assisting
40

Credentialing Specialist

Credentialing of current and new hire staff

  • Establish and update CAQH
  • Prepare verification letters
  • Maintain Insurance ID numbers and UPIN numbers
  • Establish EFT's for all Insurance payors
Candidate Info
26
years in
workforce
3
years
at this job
Computer Networking
Business Administration

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