Credentialing Specialist

MDVIP: Transforming Primary Care, One Patient at a Time

MDVIP is a national leader in personalized healthcare, empowering over 400,000 members to achieve their health and wellness goals through a network of more than 1,200+ primary care physicians. Our program emphasizes preventive medicine, offering comprehensive screenings, advanced diagnostics, and individualized wellness plans. Recognized as a Great Place to Work® since 2018, MDVIP is committed to excellence in patient care and employee satisfaction.

Role Summary

As a Credentialing Specialist, you will be responsible for reviewing and verifying the qualifications, licenses, certifications, and other relevant documents of physicians to ensure they meet the necessary standards and internal quality standards of MDVIP, including the ongoing monitoring and recredentialing of those physicians.

Credentialing & Quality Improvement:

1. Performs credentialing/recredentialing actions through the use of an outside vendor for potential affiliate physicians. Actions include but are not limited to:
2. • Processes and reviews credentialing applications to include gathering and verifying information, data entry and management, compliance checks, primary source verification, and renewal / recredentialing tracking.
   • Track application status, maintain comprehensive files, and effectively communicate application status.
   • Identifies discrepancies or missing information and effectively communicates with physicians and/or internal teams for resolution.
   • Prepares reports for internal teams to facilitate the quality of the credentialing review process.
   • Conducts research on physicians’ historical actions related to their medical license, including malpractice history review.
   • When physician information is escalated to the Credentialing Committee for review, assists in gathering and analyzing relevant facts to summarize and provide to the Credentialing Committee.
   • Maintains frequent communication with other departments on the status of the credentialing process for all physicians.

Medical Initiatives:

1. Facilitates the ongoing projects and follow-up required of the Medical Advisory Board (MAB), as needed.
2. Analyzes and interprets data reports, provides trend information and makes recommendations as needed.
3. Supports the complaint process through the investigation and resolution of the complaint.
   • Contacts members and physicians to investigate any complaints and to communicate the outcome of complaint investigation.

Corporate Initiatives: 

1. Supports and co-leads corporate initiatives identified by the Medical Initiatives Department or Executive Leadership when appropriate.
2. Formulates recommendations and assists with the development of Project Charters for approved initiatives.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education / Experience / Knowledge:

Associate degree and at least three year’s related business experience; or equivalent combination of education and experience where two year’s related experience equals one year of schooling.  Bachelor’s Degree from a four-year College or University strongly preferred.  Related experience assumes a similar corporate role focused on credentialing, quality improvement, problem resolution and/or project/process management.  MDVIP experience and prior knowledge may substitute requirements.

Computer Proficiency:

Proficient in Microsoft Office applications.  Able to learn new software easily.