Provider Credentialing Specialist II (Remote)

PURPOSE :

This role will credential dental 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. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan from home office . The incumbent will be expected to come into a CareFirst location periodically for meetings, training and / or other business related activities."

ESSENTIAL FUNCTIONS :

Responds to more complex external and internal inquiries regarding provider participation eligibility and criteria, provider data detail / structure, participation status, credentialing, contractual status and provider file updates. Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved. Professional etiquette, communications and sound decision making is required.

Analyzes more complex credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the CareFirst networks. Once verified, accepted and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.

Maintains the provider file, the provider information 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.

Responsible for identifying, analyzing, and resolving immediate and existing provider file issues through telephone calls, email, and system routes from operational areas. Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered the provider file database, ensuring a successful integration with the other corporate systems.

Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

QUALIFICATIONS :

Education Level : High School Diploma

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

• Bachelor’s Degree in Business, Healthcare Administration, or related field

Preferred Licenses / Certifications

Knowledge, Skills and Abilities (KSAs)

Department

Department :

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.