Provider Enrollment & Credentialing Specialist I (remote - Milwaukee WI only)

Location: Milwaukee, Wisconsin, United States

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Remote Opportunity: 1

Requisition Number: 3336

Position Title: Provider Enroll & Credentialing Specialist I

External Description:

External Description

JOB SUMMARY: Provider Enrollment and Credentialing Specialist Senior understands and executes all aspects of the Initial/ Re-Apply Credentialing, Re-credentialing, privileging and the onboarding process for all incoming providers. Train staff on all the credentialing criteria for practitioners that have applied to the network, including follow up with practitioners as needed to obtain information. Responsibilities also include identifying opportunities to gain efficiencies within the Provider Operations teams.

PRIMARY JOB RESPONSIBILITIES:

  • Verify potential and existing provider’s 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.
  • Review state Medicare OPT Out report for exclusion from the Medicare program.
  • Monitors and reports provider complaints and utilization management reports Assist with scheduling site reviews.
  • Enroll the provider into payment system – Windward.
  • Enter all provider information into credentialing database – Cactus and Aldera.
  • Maintain the integrity of the provider information in Windward and Cactus and Aldera.
  • 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.
  • Assist with running monthly and quarterly reports.
  • 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.

JOB QUALIFICATIONS:

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.
  • Ability to effectively train other team members (SME).
  • 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.

 

City: Milwaukee

State: Wisconsin

Community / Marketing Title: Provider Enrollment & Credentialing Specialist I (remote - Milwaukee WI only)

Company Profile:

We believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Company Profile Job:

At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system – from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.

Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it. 

To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and delivering measurable outcomes for the people we serve.

The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.

Location_formattedLocationLong: Milwaukee, Wisconsin US

CountryEEOText_Description: In accordance with our Compliance Plan, employees must conduct business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or Compliance Officer. Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program. Equal Employment Opportunity Statement: We are committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or sexual orientation.

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