Representante de Credencializacion

Representante de Credencializacion

Regular

Non-Exempt

GENERAL DESCRIPTION:

Responsible for soliciting, collecting, and validating documents necessary for the credentialing and re-credentialing of participating healthcare professionals and facilities in the provider network for all company lines of business, following the requirements of Industry regulatory agencies, Credentialing policies, and procedures.

ESSENTIAL FUNCTIONS:

• Receives, prints, stamps, and digitizes all documents received from providers by mail, fax, e-mail, or hand delivered, as state and federal regulatory agencies require.
  
• Evaluate information to ensure strict compliance with credentialing processes according to accrediting agencies and regulatory standards.
  
• Performs primary and secondary validations against the provider's credentials using Federal and State databases.
  
• Performs primary validations such as NPDB (National Practitioner Data Bank) reports, education validations, Board validations, grievances, Medicare OPT-OUT, CMS PRECLUSION LIST, EPLS (Excluded Parties List System), and OIG (Office of Inspector General).
  
• Evaluate the credentialing file and assign the Level I or II category for presentation to the credentialing committee.
  
• Verifies and documents expiring credentials, using acceptable verification sources to ensure compliance with accrediting agencies and regulatory standards.
  
• Researches and validates discrepancies and/or adverse information obtained from the application, primary source verification, or other sources to ensure that each file has all the necessary information for the Credentialing Committee's evaluation and approval process.
  
• Continuously and consistently modifies and updates provider credentials, and demographic data in the Credentialing System.
  
• If required, physically inspect medical offices and facilities to complete the required credentialing and recredentialing processes as needed.
  
• Documents the entire process in the Credentialing system, including specific documentation of all follow-ups, process progress, and pending documentation. Provides necessary follow-up to complete the process for providers following the Credentialing Policy. In the case of Providers that represent a risk due to the impact on membership, alert the management to seek other contact or contracting alternatives that minimize the impact.
  
• Receives, reviews, and guides providers personally or by telephone on the credentialing and re-credentialing process, the status of applications, and/or pending documents, among others.
  
• Prepares, maintains, and updates provider credentialing files for evaluation by the Credentialing Committee.
  
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
  
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
  

MINIMUM QUALIFICATIONS:

Education and Experience: Associate's Degree or at least sixty to sixty-four (60-64) college credits. At least one (I) year of experience performing duties in similar positions of monitoring and reporting areas, preferably in the Healthcare Insurance industry.

“Proven experience may be replaced by previously established requirements.â€

Certifications / Licenses: N/A

Other: Availability to work extended hours, weekends, and holidays as per the operations requires.

Languages:

Spanish - Intermediate (comprehensive, writing and verbal)

English - Intermediate (comprehensive, writing and verbal)

“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Accià³n Afirmativa para reclutar a Mujeres, Minorà­as, Veteranos Protegidos y Personas con Impedimentoâ€