Credentialing Specialist

Credentialing Park Ridge, Illinois


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Location: Park Ridge, IL 

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina.  In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.

Job Summary:

The Credentialing Specialist will have the responsibility for coordinating and processing provider applications for credentialing/recredentialing in the Clear Spring Health Medicare Advantage Networks.  The Credentialing Specialist will also assist the Credentialing Manager as necessary in initiating and coordinating the office support functions required for effective operational activities of the department.

Main Accountabilities:

  • Performs credentialing, re-credentialing and related activities for providers.
  • Contact providers or representatives by telephone or in writing to obtain additional information while processing their enrollment applications.
  • Screen incoming applications and paperwork for completeness and accuracy and sends necessary paperwork to credentialing vendor.
  • When necessary performs credentialing verifications and loads provider to appropriate networks and credentialing information to the provider database.
  • Reviews and processes more complex additions, updates and deletions of provider information.
  • Maintains the Clear Spring Health provider database.
  • Manage credentialing inventory, reports and projects to ensure all established time frames for completing work, reports and projects are met.
  • Create and distribute monthly reports as assigned and handle complex and unusual or high-level credentialing issues.
  • Assists in the organization of meetings of the Credentialing Committee and other designated departmental meeting which may include assistance in the preparation and distribution of the agenda, meeting materials, maintaining meeting attendance records and post meeting activities.
  • Support projects, audits, business partners, internal departments and external clients.
  • Supports the implementation of new networks, systems, software, guidelines and accreditation related activities. The Credentialing Specialist will attend, record and compile minutes of such meetings as needed.
  • Develops and maintains a current knowledge base in areas of Provider Credentialing/Recredentialing and its relationship within the organizational structure.
  • Represent department as the Subject Matter expert.
  • Pull and research necessary documentation for audits.
  • Support updates necessitated by our business partners, internal departments and external clients.
  • Provide oversight of provider files to ensure all credentialing timelines meet compliance requirements.
  • Depending on level, investigate all category II files.
  • Participate in projects which streamline, automate, or otherwise enhance credentialing functions.
  • Other duties as assigned or requested.

Knowledge & Skills:

  • Good written and verbal communication
  • Proficiency in processing providers for credentialing.
  • Proven diplomacy and a professional demeanor for effective communication with provider offices, internal personnel, vendors, accounts and committees.
  • Strong written communication and presentation skills are essential.

Requirements:

Minimum

  • High School Diploma or GED.
  • At least 1 year of experience.
  • Experience in Provider Data Management, Customer Services or Claims.
  • Microsoft Office experience (i.e. Word, Excel, PowerPoint, etc.)

Preferred

  • A familiarity with accreditation NCQA and/or URAC credentialing standards.
  • CMS Medicare guidelines