Credentialing Specialist

Provider, Facility and Ancillary credentialing, to include all aspects of new applicant credentialing, re-credentialing; ongoing maintenance of provider credentials; online verifications; administrative support of credentialing functions.

Essential Functions:
  • Review new applications and supporting documents in a virtual environment and apply policy and criteria required for credentialing processing.
  • Perform all required primary source verifications.
  • Contact hospitals, licensing agencies, malpractice carriers, and medical schools to obtain credentialing verifications.
  • Maintain and update credentialing database records.
  • Review malpractice history, regulatory and disciplinary action reports issued by state and federal agencies invoking appropriate processes as defined in policies and procedures.
  • Review the CAQH system and download applications or supplemental documents as appropriate.
  • Maintain electronic provider files.
  • Perform outreach to providers and facilities via phone calls and fax/email correspondence.
  • Demonstrate knowledge of credentialing regulatory and accreditation requirements (NCQA, CMS, Medicaid, etc.).
  • Perform other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    Candidate Experience:
    • Required 2 years of experience in a customer service or healthcare related position
    • Preferred 1 year of experience in Credentialing
    Candidate Skills:
    • Intermediate Demonstrated written communication skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to work as part of a team
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Other Knowledge of credentialing software sufficient to develop appropriate reports on all aspects of credentialing
    Licenses and Certifications:
    A license in one of the following is required:
    • Preferred Other Certified provider credentialing specialist or directly related or equivalent work experience
    Technical Skills:
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Other Ability to learn various software packages as may be necessary to perform job functions

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.