Credentialing Specialist

JOB SUMMARY

The Credentialing Specialist is responsible for screening reviewers for required credentialing and background information, including professional sanctions and criminal background information. The position requires coordination between multiple departments at Dane Street to provide support relating to the information, data, and standards involved in reviewer credentialing.

Dane Street’s success relies on individual and team contributions every day. We care for our customers, each other and Dane Street. It is the responsibility for all of us to maintain a positive working environment that promotes client satisfaction and results.

MAJOR DUTIES & RESPONSIBILITIES

• Initial Credentialing: Enters reviewer application data, performs online searches of reviewers, conducts primary source verification of reviewer board certifications, licenses, background checks, and malpractice checks. Uploads documents to the electronic reviewer file, produces Judgments page to include comments from the Medical Director. Applies client Do Not Use status as required. Communicates the application status with the Operations team, including when an application is denied by the Medical Director.

• Recredentialing of Reviewers: Sends applications to reviewers, conducts prime source verification of board certifications, licenses, and malpractice checks. Performs online searches of reviewers. Refers reviewers with “red flags” to the Medical Director for review. Indicates Do Not Use status and Medical Reviewer comments in Judgments document.

• Updating Expired Licenses, Board Certifications, and Workers’ Compensation Registration: Reviews licenses, certifications, and registrations for expiration status.

• Exclusions, Preclusions, Background and Sanction Checks: Creates and receives sanctions check clearinghouse reports and search for each sanction identified. Finds supporting documentation, including court documents or National Practitioner Data Bank reporting. Sends information to the Medical Director for review.

• Reactivating, Deactivating, Do Not Use, Reviewer Contact Data and W9 Requests: Obtains W-9 documents in response to address changes. Clones profiles in the event of a fundamental identifying data change. Removes reviewers from the panel based on client or Operations department requests.

• Editing Fee Schedules: Performs data entry of new fees or updated fees. Obtains new fee agreements as appropriate.

• Participation on the Quality Management Committee: Participates in the Quality Management Committee meetings, which is required by URAC but incorporates Dane Street quality improvement functions. Participation includes requested follow up activities.

• Assist Dane Street Team Members with Credentialing Content: Provides credentialing related advice to leadership and for contracting and Operations functions.

Other duties & special projects, as assigned and based on business needs.

Requirements

EDUCATION/CREDENTIALS:

An Associate’s Degree or Bachelor’s Degree is preferred.

JOB RELEVANT EXPERIENCE:

Credentialing experience in a healthcare or insurance setting preferred. .

JOB RELATED SKILLS/COMPETENCIES:

Knowledge of URAC and relevant State and Federal guidelines. Excellent communication skills as well as understanding of medical terminology. Critical thinking, ability to manage time efficiently and to meet specific deadlines. Computer literacy and typing skills required.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

WORK FROM HOME TECHNICAL REQUIREMENTS:

Supply and support their own internet services.

Maintaining an uninterrupted internet connection is a requirement of all work from home position.

This job description is subject to change at any time.

Benefits

Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace. 

ABOUT DANE STREET:

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

Last updated on Aug 22, 2024