Regular
Exempt
GENERAL DESCRIPTION:
Responsible for evaluating and managing the credentialing and recredentialing processes for healthcare professionals and facilities participating in the provider network across all lines of business. Ensures compliance with regulatory requirements, accreditation standards, and company policies, maintaining the integrity and quality of the provider network.
ESSENTIAL FUNCTIONS:
Evaluates provider credentialing and recredentialing applications for completeness and adherence with accrediting agencies and regulatory standards.
Conducts primary and secondary source verifications in systems such as National Practitioner Data Bank (NPDB), Center of Medicare and Medicaid Services (CMS) Preclusion List, Office of Inspector General (OIG), Excluded Parties List System (EPLS), state licensing boards, and educational institutions.
Analyze and investigate discrepancies or findings in applications. Coordinate follow-up actions, escalate critical issues, and ensure files are complete and accurate before the committee review.
Assign credentialing levels (Level I or Level II) based on risk and provider type. Prepare and present completed files for review and determination by the Credentialing Committee.
Track, verify, and update expiring credentials, licenses, and certifications. Maintain ongoing monitoring logs and ensure compliance with continuous monitoring requirements.
Document all credentialing activities, decisions, and communications in the credentialing system, and notify management of any potential risks or delays affecting provider participation or member access.
Performs on-site inspections of medical offices and facilities as required for credentialing and re-credentialing processes.
Serve as a liaison to providers during the credentialing process, delivering timely updates, clarifying requirements, and supporting the resolution of documentation.
Identify and report any findings such as sanctions, exclusions, or opt-outs to the management and Compliance department, and initiate and document termination or suspension procedures when necessary.
Updates provider demographic and contact information in the credentialing system, ensuring data accuracy and compliance with policy standards.
Collaborates with other departments to ensure timely, accurate credentialing processes and provider data updates.
Perform essential operational tasks within the unit and monitor provider documents received, ensuring compliance with federal and state regulations.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Minimum Qualifications
Education and Experience: Bachelor's Degree in Business Administration, Healthcare Administration, or related fields. At least two (2) years of experience performing duties in similar positions of monitoring and reporting areas, credentialing, or provider network operations, preferably in the Healthcare Insurance industry.
OR
Education and Experience: Associate's Degree or at least sixty to sixty-four college credits. At least four (4) years of experience performing duties in similar positions of monitoring and reporting areas, credentialing, or provider network operations, preferably in the Healthcare Insurance industry.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses: A valid driver's license in the Commonwealth of Puerto Rico is required. Other: Car in good condition and available to travel to different locations in Puerto Rico. Knowledge of state, federal, and accreditation requirements in the Healthcare Insurance Industry is preferred. Knowledge of credentialing and recredentialing processes, and databases/systems.
Languages:
Spanish – Advanced (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
"We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities."
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