Career Opportunity

Credentialing & Data Management Specialist

General Summary
Responsible for credentialing, re-credentialing and privileging processes for all medical providers.   Monitor many aspects of the quality payment program MIPS. Manage data collection for MIPS, IRIS, Open Payments, and other data dashboards.  Design reports for monthly, quarterly meetings and ad hoc reports as needed.


Essential Job Responsiblities

1.      Compiles and maintains current and accurate data for all providers regarding credentialing and re-credentialing applications; monitors applications and follows-up as needed.

2.      Processes application for appointment and re-appointment of privileges for all providers.

3.      Maintains and tracks state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.

4.      Maintains knowledge of current health plan and agency requirements for credentialing providers.

5.      Sets up and maintains provider information in online credentialing databases and system.

6.      Ensures practice addresses are current with health plans, agencies and other entities.

7.      Maintains provider appointment files, and information in credentialing database.

8.      Audits health plan directories for current and accurate provider information.

9.      Problem solves EDI issues related to credentialing and transaction rejections, maintain EDI and EFT application and enrollments.

10.  Manages HIPAA privacy and security regulations.

Data Management:

11.  Works with Manager, Quality and Risk to facilitate accurate, complete and timely reporting of annual MIPS reporting.

12.  Track and monitor community reporting requirements (MNCM) and FPA reporting requirements.

13.  Uploads quality results and disseminate to Manager, Quality and Risk.

14.  Helps identify and contribute to ways to improve MIPS scores.

15.  Compares OIG LEIE lists to current employee and vender lists, monthly. Prepare report for quarterly meetings.

16.  Maintains MSDS updates, quarterly.

17.  Collects signatures as needed from providers for annual education, credentialing, and privileging as needed.

18.  Performs other related duties as assigned. 

Education, Certification and License Requirements
1.      High school diploma or equivalent.

2.     Associate degree preferred.

Certification/Licensure: Certified Provider Credentialing Specialist (CPCS) preferred.

Two years of relevant credentialing experience preferred.
Other Requirements
1.      Knowledge and understanding of the credentialing process.

2.       Ability to organize and prioritize work and manage multiple priorities.

3.      Excellent verbal and written communication skills including, letters, memos and emails.

4.       Excellent attention to detail.

5.      Ability to research and analyze data.

6.      Ability to work independently with minimal supervision.

7.      Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.

8.      Proficient use of Microsoft Office applications and internet resources.

9.      Travel between clinics is required as needed.

Work Environment
  • Professional office setting.
  • Normal indoor working conditions, moderate noise levels.