Provider Enroll & Credentialing Support Specialist, DentaQuest

Overview

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week.

Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you!

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life.

We will make reasonable accommodations to the known physical or mental limitations 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 email  to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice. We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Title: Provider Enrollment and Credentialing Specialist

The provider enrollment and credentialing specialist reviews all aspects of initial/re-apply credentialing, re-credentialing, privileging and oversees the onboarding process for all incoming providers. Primary responsibilities include verifying credentialing criteria for practitioners applying to the network and following up with practitioners as needed to obtain information.

• Verify potential and existing provider’s licensure, NPI, insurance, CDS, DEA certificate, education, hospital privileges, board certification.
• Contract validation: review contract and application for completeness.
• Review National Practitioner 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.
• Monitor and report 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.
• Maintain the integrity of provider information in Windward and Cactus.
• Ensure credentialing file is in order with any issues flagged for committee.
• Meet required turnaround time and accuracy rate.
• Assist with other duties as assigned.
• Assist management in the implementation of department process improvements.
• Assist with ongoing NCQA certification activities.
• Represent Denta Quest in a professional manner at all times when communicating with internal and external requestors.
• Maintain confidentiality of credentialing information.
• Other duties as needed or required.

• High School Diploma or equivalent.
• 1 year job related experience.
• Previous experience working with files or the collection and coordination of data preferred.
• Knowledge of dental terminology preferred.
• Good interpersonal skills.
• Ability to work independently.
• Excellent oral and written communication skills.
• Efficient PC skills (Word, Excel, Outlook, Work Flow Software, Time Tracking Systems).
• Ability to learn new software programs quickly.
• Ability to prioritize and organize multiple tasks.
• Ability to remain organized with multiple interruptions.
• Good customer service and problem resolution skills.
• Ability to navigate websites needed for credentialing purposes.
• Ability to adapt to a constantly changing environment.
• Ability to work in excess of 40 hours in a week.
• Required to attend additional training as…