Credentialing Specialist

PacificSource Health Plans • Springfield, OR

397d

About The Position

The Credentialing Specialist at PacificSource Health Plans is responsible for obtaining and maintaining critical provider credentialing data necessary for initial and recredentialing reviews. This role ensures the selection of providers who possess the clinical skills necessary to deliver high-quality healthcare and service excellence to members. The specialist will follow credentialing procedures, accreditation, and regulatory requirements to ensure timely and accurate credentialing of practitioners affiliated with PacificSource.

Requirements

• Minimum of two years health insurance experience or equivalent required.
• Credentialing experience preferred.
• High School Diploma or equivalent required; Associate Degree preferred.
• NAMSS Certified Provider Credentialing Specialist Certification (CPCS) preferred.
• Effective written and verbal communication skills.
• Highly organized with strong interpersonal skills.
• Knowledge of NCQA credentialing standards and state regulatory requirements.
• Knowledge of policy and procedure development.
• Computer skills, including word processing, spreadsheets, and database applications.

Nice To Haves

• Experience in a healthcare setting.
• Familiarity with HIPAA laws and regulations.

Responsibilities

• Input and maintain practitioner data in the computer database.
• Review, research, and verify practitioner files and database records to compile data for reports.
• Perform essential credentialing activities related to credentialing and recredentialing operations.
• Organize project work and maintain inter-departmental contacts regarding credentialing issues.
• Conduct primary source verification on applicants, including requests, investigations, and verifications of documents.
• Maintain familiarity with requirements of NPDB, State Medical Boards, NCQA, CMS, and PacificSource credentialing policies.
• Manage and respond to high volume internal and external customer inquiries via email, telephone, and in person.
• Collaborate in a team environment and reassess primary job responsibilities as necessary.
• Maintain collaborative relationships with IPAs/Delegates, practitioners, and their staff.
• Review monthly reports to ensure practitioners complete recredentialing on time.
• Prepare reports and summaries on practitioners with adverse actions for the Credentialing Committee.

Benefits

• Health insurance coverage.
• 401k retirement savings plan.
• Paid time off and holidays.
• Professional development opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED