Credentialing Specialist

Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.

Position Summary

The Credentialing Specialist is responsible for supporting the process functions related to the credentialing and re-credentialing of health plan providers (including facilities) to ensure they meet the necessary requirements and credentialing standards/regulations (CMS/NCQA/DoD) for acceptance and continued participation as a network provider of Martins Point Health Cares multiple health plans/product lines. This individual is also responsible for assisting with the daily management of an external Credentialing Verification Organization (CVO) that provides provider and facility primary source verification services to Martins Point Health Care (MPHC).

Job Description

Key Outcomes:

• Maintains up-to-date knowledge of NCQA CMS standards and DoD requirements as they relate to the credentialing function as well as MPHC Credentialing and Network Management departmental policies and procedures and applies them appropriately based on the providers contractual status
• Receives primary source verification information from CVO. Acts as point person between MPHC and CVO. Determines if detailed Credentials Committee review is required based on exception criteria
• Conducts primary source verification of credentials as required through utilization of credentialing software interfaces direct contact and/or industry approved verification websites
• Responsible for the accuracy and integrity of credentialing data
• Ensures the timeliness of credentialing/re-credentialing verification/processing
• Enters provider data and verification information into credentialing software database and adds appropriate documentation to the provider credentialing file based on standard departmental format and policies and procedures
• Collaborates with other departments to define/clarify provider applicant status and demographics as well as streamlining application processes and information exchanges and ongoing monitoring to ensure the provider continues to meet participation criteria

• Reviews exceptions/red flag cases to ensure all information is obtained to present cases for peer review
• Audits credentials files/processes to ensure compliance with regulatory and accreditation standards providing education/improvement activities as appropriate
• Responsible for monthly Credentials Committee preparation and follow-up as applicable
• Manages the Credentials Committee process by preparing providers files photocopies and collates provider packages for each committee member
• Prepares routine provider/facility lists for the committee chair to sign
• Responsible for managing the Ongoing Monitoring process between credentialing cyclesTasks include but are not limited to quering state agencies to gather information on providers with sanctions tracking network providers with sanctions and if applicable reviewing cases with the Credentialing Committee chairperson
• Begins preparation of incoming initial applications with Network Management Provider Operations Representatives to pass on to CVO to ensure applicant meets the established internal participation criteria for acceptance.
• Compiles data and maintains databases/spreadsheets to support operational tracking needs
• Provides filing of documents letter and mailing production report generation and support on special projects.
• Maintain ongoing relationship with network wide credentialing delegates including monthly and ad hoc reporting agreement review on-site file audits and policy and procedure review
• Preparation and participation in NCQA on-site file audits.

Education/Experience:

• Bachelors Degree or equivalent combination of relevant education and experience
• 3 years relevant experience required.
• CPCS certification through the National Association Medical Staff Services preferred but not required.

Skills/Knowledge/Competencies (Behaviors):

• Strong proficiency in Microsoft Office and the ability to learn applications that support the credentialing process.
• Ability to manage organize and prioritize workload in a timely accurate manner
• Excellent communication and interpersonal skills and ability to manage internal and external relationships
• Knowledge of NCQA CMS and DoD credentialing standards
• Commitment to continue credentialing training and education
• Strong attention to detail

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martins Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process to perform essential job functions and/or to receive other benefits and privileges of employment please contact

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