Credentialing Rep

Job Description

Job Description

Under the direct supervision of the Manager of Credentialing, responsible for credentialing of providers and associated activities in support of the credentialing process in accordance with established Health Plan credentialing policies following NCQA, Medicare, the state of West Virginia, West Virginia Medicaid, and the state of Ohio policies and procedures.

Required:

1. High school diploma or equivalent.
2. At least two years related healthcare experience.
3. Strong organizational, interpersonal, and critical thinking skills.
4. Excellent communication skills, both written and verbal
5. Ability to multi-task, prioritize workload to meet deadlines, and pay meticulous attention to detail.
6. Ability to troubleshoot, problem solve and work as a team as well as independently.
7. Experience in Microsoft Office Programs such as Word, Excel and Adobe Acrobat.

Desired:

1. College Degree.
2. Previous credentialing experience.
3. CPCS Certification.
4. Experience with data systems.
5. Knowledge of medical coding and terminology.

Responsibilities:

1. Performs provider credentialing and recredentialing functions.
2. Daily monitoring of application status and documents progress on tracking log.
3. Review and process providers initial credentialing and recredentialing applications and supporting documentation to identify possible issues. Follows up with responsible party to obtain missing information.
4. Ensure that recredentialing applications are completed timely to prevent any lapse in participation.
5. Identifies credentialing applications with variances and compiles information for credential committee review.
6. Accurate data entry, document scanning, and navigation of provider data systems.
7. Adheres to all policies and procedures of The Health Plan and other regulatory/governing entities as well as following standards established by NCQA, CMS, BMS, and the states of West Virginia and Ohio.
8. Assists with national, state, and internal audits.
9. Works collaboratively with the Provider Delivery Services team as well as all internal departments.
10. Teamwork to manage credentialing application volume.
11. Assists with training and development of employees related to the credentialing process.
12. Performs monthly reviews of applicable state licensing boards to identify adverse actions.
13. Performs monthly reviews of government exclusion databases.
14. Maintains confidentiality of provider information.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.