Responsible for all activities associated with
credentialing or re-credentialing providers for the HMO and PPO and TriWest network.
Duties may include processing provider applications, research, verifications
and preparation of files for Credentialing Committee review. Communicates with
internal departments and external sources to exchange information and verify
data. Tracks and maintains provider information including grievances and QI
Gathers data, reviews for completeness and
accuracy, analyzes potential problems and recommends appropriate action. Monitors timeliness in receipt of information
and follows-up as needed.
Identifies questionable or highly sensitive
information and refers to appropriate sources for further research.
Enters credentialing data into system and tracks
and maintains provider information in credentialing system.
Works with internal departments to exchange
provider information and follows up on identified issues.
Identifies procedural and systems problems and
brings them to Supervisor's attention; makes recommendations where appropriate.
May review reports from regulatory and
controlling oversight agencies. May
summarize provider files to facilitate committee review or prepare detailed
documentation related to formal reviews.
Assures a great customer service to CBS
practitioners and responds to their inquiries regarding credentialing status or
any other requests timely and in professional manner.
Participates in file reviews for audit
Performs general office duties such as scanning,
duplicating, sorting, mail distributions, etc
Performs additional tasks as assigned
High school diploma or GED and/or a combination
of equivalent experience. Basic
knowledge of credentialing or health care.
Effective oral and written communication skills
and ability to handle sensitive information and issues with tact and
Minimum Experience Level
Typically requires 2 years experience,
preferably in credentialing.
Knowledge of NCQA, CMS and DMHC requirements