Join Martin's 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 of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's 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 Martin's Point has been certified as a "Great Place to Work" since 2015. The Credentialing Specialist is responsible for managing 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 Martin’s Point Health Care’s multiple health plans/product lines. This individual is also responsible for the daily management of an external Credentialing Verification Organization (“CVO”) that provides provider and facility primary source verification services to Martin’s Point Health Care (MPHC).
- 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 provider’s 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
- Partners with key stakeholders from Informatics, MCA (Managed Care Applications) and IT, to advance the organization’s provider data architecture process improvement efforts.
- Responsible for the accuracy and integrity of credentialing data
- Ensures the timeliness of credentialing/re-credentialingverification/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 provider’s files, photocopies and collates provider packages for each committee member
- Prepares routine provider/facility lists for the committee chair to sign
- Facilitates the Credentials Committee meeting
- Responsible for managing the Ongoing Monitoring process between credentialing cycles—Tasks 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
- Responsible for compiling the HEDIS credentialing roadmap and BCR metrics
- Preparation and participation in NCQA on-site file audits.
- Bachelor’s Degree or equivalent combination of relevant education and experience required
- 4+ Years relevant experience
- CPCS certification through the National Association Medical Staff Services required within 1 year of hire
- 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
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: firstname.lastname@example.org