Credentialing Specialist

Develop and cultivate productive relationships with providers, retail chains, strategic partners, and their staff. Elevate providers’ understanding of industry-standard credentialing requirements, leveraging team knowledge and resources.

Essential Functions

Establish relationships with providers to obtain required regulatory information and manage all aspects of the provider’s initial and ongoing credentialing requirements

Use independent judgment to ensure that documentation complies with appropriate state regulations

Oversee and manage assigned files in CVO partner’s system

Track in-progress credentialing files, identify and collect missing documents to ensure timely completion of the credentialing process for new and existing providers and that state regulatory standards are met

Research, analyze, and resolve complex credentialing issues and escalations, coordinating with internal and external business partners when needed in order to meet regulatorily compliance requirements

Use analytical and investigative skills to collect, evaluate, and compile information from regulatory reporting agencies, legal documents, and the provider to support explanation of provider sanctions and/or malpractice claims

Compile required information for the Credentialing Committee in a clear and complete format that allows the Committee to render their decision on the provider’s application

Exercise critical thinking and analytical skills in the initial entry and maintenance of provider data, ensuring the integrity of all shared provider information

Escalate issues to the appropriate business areas and drive solutions when applicable

Gather and assess necessary provider information for the legal department to support the Dispute Resolution Process for providers denied at Committee or termed from the network

Compose professional and concise correspondence to providers, retail chains, and office staff

Demonstrate a broad knowledge of the organization's strategic direction to achieve growth objectives and operational goals. Act as an internal resource for business partners

Job Specifications

Typically has the following skills or abilities:

Bachelor's degree in a related field; in lieu of degree, 4 years functional experience

Demonstrated professionalism and leadership in dealing with situations involving controversy and conflict; experience handling and resolving escalated issues

Demonstrated advanced communication, influencing, and problem-solving skills

Experience working directly with providers and staff on credentialing policies and procedures

Regularly exercise discretion and independent judgment in the performance of job duties

Demonstrated ability to identify problems and provide creative solutions

Strong attention to detail, multitasking, organizational skills, and customer service skills

Proven ability to balance provider needs with corporate objectives

Ability to work independently and in a team environment

For roles that are remote (i.e., Work From Home (WFM)) or hybrid (i.e., partial onsite at a VSP location and WFM), must demonstrate a high level of engagement in virtual environments, including maintaining camera presence during meetings to support effective communication and team alignment