Specialist, National Credentialing

Specialist, National Credentialing at Molina Healthcare

Provides support for Molina enterprise credentialing activities. Ensures that the Molina provider network consists of providers that meet all regulatory and risk management criteria - effectively minimizing liability to the company and maximizing safety for members. Responsible for initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations in the Molina network.

Essential Job Duties

• Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.
• Communicates with health care providers to clarify questions and request any missing information.
• Updates credentialing software systems with required information.
• Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.
• Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.
• Completes data corrections in the credentialing database necessary for processing of recredentialing applications.
• Reviews claims payment systems to determine provider status, as necessary.
• Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals.
• Reviews and processes daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.
• Reviews and processes daily alerts for Medicare opt-out reports to determine if any provider has opted out of Medicare.
• Reviews and processes daily National Practitioner Data Bank (NPDB) continuous query reports and takes appropriate action when new reports are found.
• Maintains a high level of confidentiality related to provider information.

Required Qualifications

• At least 2 years of experience in a data processing, production, and/or administrative role - preferably in a health care setting, or equivalent combination of relevant education and experience.
• Data entry skills.
• Self-direction and logical thinking abilities.
• Internet research experience.
• Ability to work cross-collaboratively in a highly matrixed organization with internal/external stakeholders.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Health care industry experience.
• Credentialing experience.
• Knowledge of Medicaid, National Committee for Quality Assurance (NCQA) and other credentialing regulations.

Key skills/competency

• Credentialing
• Data Entry
• Regulatory Compliance
• Healthcare Administration
• Provider Network
• Risk Management
• Sanctions Monitoring
• NPDB
• Communication Skills
• Microsoft Office