Provider Enrollment & Credentialing Specialist I ( Florida )
DentaQuest

Orlando, Florida


JOB SUMMARY: Provider Enrollment and Credentialing Specialist understands and executes all aspects of the Initial/ Re-Apply Credentialing, Re-credentialing, privileging and the onboarding process for all incoming providers. Responsibilities also include identifying opportunities to gain efficiencies within the Provider Operations teams.

PRIMARY JOB RESPONSIBILITIES:

  • Verify potential and existing providers licensure, NPI, insurance, CDS, DEA certificate, education, hospital privileges, board certification.
  • Review National Practitioners Data Bank for adverse charges pending or filed against Provider.
  • Review federal and/ or state OIG and SAM report for exclusion from the Medicaid or Medicare program.
  • Monitors and reports provider complaints and utilization management reports Assist with scheduling site reviews.
  • Enter all provider information into credentialing database Cactus.
  • Maintain the integrity of the provider information in Windward and Cactus.
  • Assist with processing provider approvals.
  • Ensures credentialing file is in order with any issues flagged for committee.
  • Meet required turnaround time and accuracy rate. Coordinate and complete special projects as needed.
  • Assist management in the implementation of department process improvements.
  • Assist with the ongoing NCQA certification activities.
  • Provide training to Provider Operations staff, Provider Relations or other DentaQuest staff as needed on procedures, processes, requirements and/ or system changes.
  • Represent DentaQuest in a professional manner at all times while communicating with internal and external requestors. Maintains confidentiality of the credentialing information.
  • Ability to independently, accurately, and timely resolve credentialing issues presented by an external or internal customers.
  • Collaborate with the team to identify opportunities for improvement both within the department and interdepartmental. Assist in resolving escalated provider set up issues.
  • Other duties as needed or required.

Required:

  • Associate degree or equivalent experience required.
  • 2 years related experience
  • Strong interpersonal skills.
  • Knowledge of Dental terminology required.
  • Knowledge of credentialing criteria, requirements and processes required.
  • Ability to work independently.
  • Excellent oral and written communication skills.
  • Proficient using department software (Credentialing and Enrollment Systems, Word, Excel, Outlook, Work Flow Software, Time Tracking Systems).
  • Ability to learn new software programs quickly.
  • Systematic, detail oriented, process and outcome driven.
  • Excellent analytical ability.
  • Ability to prioritize and organize multiple tasks.
  • Ability to remain organized with multiple interruptions.
  • Excellent customer service and problem resolution skills.
  • Ability to independently or with minimal guidance, complete assigned projects/tasks.
  • Ability to use good judgment and make quick independent decisions.
  • Cooperative, professional, and effective interaction skills with co-workers, company staff and clients.
  • Ability to clearly document processes including the use of Visio.
  • Active participation in team/department meeting and assist department in identifying areas of opportunity while driving solutions. Ability to work in excess of 40 hours per week, as needed or required to meet business objectives.
  • Required to attend additional training as requested/deemed necessary.

Preferred:

  • 5+ years of related experience preferred.
  • Certified Provider Credentialing Specialist Certification Preferred.

PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.

, Orlando, Florida 32828



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