Contract and Credentialing Specialist

Description

ABOUT PRECISION DIAGNOSTICS: 

Precision Diagnostics (“Precision” or the “Company”), based in San Diego, California is a fast-growing laboratory that specializes in providing quantitative drug testing, primarily for helping physicians monitor their patient’s undergoing treatment for pain or substance abuse. Precision’s objective is to improve patient adherence/compliance with their prescription regimen and protect medical practices from liability. 

THE ROLE: 

We are seeking a Contract & Credentialing Specialist to join our Payor Contracting Department. This role ensures that all facilities maintain accurate and up-to-date credentials. Responsibilities include managing and processing initial credentialing, revalidation/recredentialing requirements, and contracting applications, including letters of interest, for our laboratory at both regional and national levels. Key duties involve performing primary source verification for contracting and licensure, monitoring license updates nationwide, and ensuring compliance with state and federal accrediting requirements. 

The Specialist will report to the Director of Managed Care and must demonstrate comprehensive knowledge of regulations, standards, and practices necessary to achieve and maintain licensure, credentials, and managed care contracts. This position requires a thorough understanding of medical policy and managed care contracts, along with the ability to effectively interact with medical professionals, office personnel, and other stakeholders. 

OUTCOMES: 

• Initiate payer outreach and begin application/contracting process as needed. 
• Draft Letters of Interest (LOI) and proposals to contract as requested. 
• Follow up on LOI’s in a consistent manner. 
• Professionally request reconsiderations of unaccepted / denied proposals as appropriate. 
• Set up EDI / ERA / EFT enrollment for payers as needed. 
• Demonstrates good judgment in selecting methods and techniques for obtaining solutions. 
• Ability to effectively provide communication on issues or complex information to a wide audience based on knowledge. 
• Answer and respond to complex questions and inquiries via telephone and electronic messaging systems utilizing established procedures. 
• Work under minimal supervision and assist less experienced peers. 
• Sound independent judgment about problem solving and troubleshooting. 
• Responsible for gathering and performing a detailed and thorough review to include basic level analysis to ensure that all documents have been received in support of a complete initial credentialing or recredentialing applications. 
• Assemble electronic files and prepare credential files for submission & processing for next level evaluation. 
• Follow up with various departments / personnel to acquire any missing information while timely tracking for completion.  
• Review of the application prior to expiration of credentialing/network membership to ensure all credentials remain current. 
• Create the appropriate cycle credentialing effort in the corresponding system to initiate the credentialing verification process. 
• Track, verify, and document expirable / current credentials using acceptable verification sources to ensure compliance with accreditation and regulatory standards. 
• Tracks and obtains documents and applications from providers prior to recredentialing expiration in compliance with our payer contracts, policies and procedures, and state or federal regulations. 
• Manage and maintain current copies of all medical license records for management/ laboratory directors, ownership, and all required credentialing documents for the laboratory.  
• Maintain corporate provider contract/ agreement files. 
• Maintain credentialing database and continuous, consistent data integrity to ensure that accurate and current information is available to all systems and departments. 
• Performs other credentialing / contracting duties as requested. 
• Data entry and follow up in credentialing software. 
• Release information to agencies and members of the public as required by law 
• Maintain a contract repository with rate sheets for stakeholders. 
• Displays a competent knowledge of Agency policy and procedures as well as Federal and State Regulations. Keeps current with available resources. 
• Maintains confidentiality, proper boundaries and an ethical relationship with clients and co-workers according to Company's policies. 

WHAT YOU BRING TO THE TABLE: 

• Healthcare Industry experience with focus on provider credentialing/enrollment required, facility credentialing preferred.
• Experience with computer systems required, including web-based applications and Microsoft 365 applications which include Teams, Word, Excel, PowerPoint, Lists and PDF.
• Minimum 3 years of relevant experience
• Bachelor’s degree in relevant area
• NAMSS Certified Provider Credentialing Specialist (CPCS) preferred.
• Experience and proven success in federal and state compliance guidelines in a medical setting.
• Knowledge of the U S Healthcare system and workers compensation industry. 
• Excellent verbal and written communication skills as well as listening skills and reading and writing comprehension to technical and non-technical audiences of various levels within the organization (e.g., executive, management, individual contributors). 
• Excellent problem solving, time management, and work prioritization skills. 
• Requires proficient negotiation skills and tactics, both written and verbal. 
• Self-starter with experience handling high work volume and multiple projects. 
• Ability to establish and maintain positive relationships with internal and external customers and be a team player. 
• Ability to think and work effectively in a high-pressure environment. Comfortable with change and possesses the ability to switch tasks and priorities seamlessly. Ability to adapt behavior in response to new information or changing circumstances. Is open to change and new information, ideas, methods, or approaches.  
• Work and collaborate effectively and adjust to original objective or plan to allow for the best possible results. 
• Must be able to successfully maintain multiple projects simultaneously, manage and meet multiple deadlines, be detail-oriented, and possess strong organizational skills. 
• Meets expectations and department timeliness commitments. Complies with Accreditation and Regulatory Standards in addition to compliance with State and Federal Accreditation Standards and Regulatory Requirements. 
• Exercise independent thinking and judgment. 
• Ethical conduct and the ability to respect and preserve confidential information entrusted in the course of professional duties is necessary. Reveals confidential information only to appropriate parties and in accordance with any applicable law. Maintains confidentiality regarding legal matters, privacy issues, information technology, and data integrity. 
• Quality of Work: freedom from errors and mistakes with the ability to consistently meet objectives; high attention to detail. 
• Clerical office, data entry, e-filing, and customer interfacing/communication experience required (preferably in a healthcare setting). 
• Performs other related duties as assigned. 
• Communicates with director and associates regarding credentialing status,  
• information, and maintain current documents as required.  
• Review applications for completeness and confidential information collection, verification, and documentation in accordance with established policies and procedures for continuous credentialing and re-credentialing of facility and/or facility locations. 
• Collaborates with credentialing management on the streamlining and updating of credentialing processes. 
• Initiates and follows through on all aspects of the credentialing process, including initial and follow up credentialing, for all the insurances company is contracted with. 
• To be successful, you agree that technology is a key part of every business process, and you will make new technology adoption part of your routine. 
• Become fluent in Microsoft 365 (formerly Office635) applications assigned to your role. Common applications include Teams, Word, Excel, Tasks and Planner 
• Complete training in a timely manner that is assigned to you. Training is primarily conducted via Microsoft Learn modules and is assigned based on: 
  • Position/Job Role – Most positions require a core set of Microsoft 365 working knowledge 
  • Project Role – As member of a project team, you may be required to complete training before you can engage with the project team or commence project work 
  • Ad-Hoc – Based on review of your performance via support requests, training modules will be assigned to increase skills 

WHAT WE BRING TO THE TABLE: 

• Comprehensive benefits package: Medical, Dental, Vision, and additional optional coverages   
• 401K with company match   
• Paid time off and paid Holidays  
• Precision is dedicated to giving back to our communities through various platforms such as: 
  • Sponsoring high school students with limited economic means 
  • Annual company food drive with Precision matching each employee donation 
  • Precision Cares program, partnering with local communities each year to give back 
• Frequent company events to keep our employees connected such as: 
  • Lab Week: To celebrate and recognize the value our Lab Team members contribute 
  • Compliance Week: To shine a light on the importance of compliance & ethics 
  • National Sales Meeting in San Diego for all Sales team members to connect and learn 

ADDITIONAL JOB CONSIDERATIONS: 

• For roles located in office or home settings; this job is primarily sedentary and may involve repetitive motions; the employee is regularly required to sit, use hands and fingers, speak, and hear. 
• The employee is occasionally required to stand, walk, and lift objects (up to 10 lbs. weight; up to 4 ft. height). 
• Specific vision abilities required by this job include the ability to see things from a close distance and the ability to adjust focus. 
• Role must be available to attend video / audio team calls daily 
• Please be advised this job description is subject to change at any time.  
• This position is temporary full time with possible move to permanent full time 
• 8 hour shift, M-F 8am PST to 4pm PST 
• The hourly range for this role is $28-$32
• Must be able to sit at a desk for prolonged periods and work on a computer.   

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.    

Precision is an equal-opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. 

This policy applies to all employment practices within our organization, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Precision Diagnostics makes hiring decisions based solely on qualifications, merit, and business needs at the time. 

Qualifications