Credentialing Representative

Credentialing Representative

The Credentialing Representative is responsible for the credentialing and recredentialing of providers in compliance with NCQA, CMS, DOI, state credentialing standards and HealthOne Alliance policies and procedures. This includes entering data, performing appropriate credentialing verifications, preparing, and presenting at Credentialing Committee Meetings, preparing for Board of Directors reviews and notification of the completed credentialing process. This role will assist in the monitoring of license expirations and status changes and take action when appropriate. The position also helps to review and update criteria and credentialing policies and procedures, as necessary, but no less than annually.

Essential Job Duties:

• Works directly with providers to ensure all necessary credentialing information has been received prior to beginning the credentialing process
• Provides timely follow-up to obtain required documentation to complete the credentialing process
• Enters provider data into appropriate data management systems
• Performs all credentialing verifications necessary to complete the credentialing process while maintaining the appropriate compliance standards in an electronic format
• Prepares and presents providers records for Credentialing Committee Review
• Prepares Credentialing Committee recommendations for Board of Directors review
• Notifies providers of credentialing decisions within compliance timeframes
• Assists providers with all questions related to provider credentialing
• Performs provider re-credentialing, at least every 36 months in compliance with NCQA standards
• Assists with ensuring providers are compliant with the NCQA, CMS, DOI and state requirements regarding availability and access standards and evaluates the standards to ensure they address the requirements outlined by NCQA, CMS, DOI and state
• Ability to take direction and quickly adapt to changing guidelines and standards
• Assists with preparing credentialing files for delegation audits
• Assists in monitoring of license expirations and status changes in LEMM and takes action when appropriate
• Assists in reviewing and updating criteria and credentialing policies and procedures, as necessary, but no less than annually
• Educates providers and the Provider Relations regarding criteria and credentialing policies and procedures when necessary
• Works with Network Management to ensure providers' initial information and updates are sent for processing timely and accurately
• Assists Network Management and Provider Relations with changing a provider from a direct relationship to delegated relationship
• Maintains provider and patient confidentiality at all times
• Provides positive, supportive, communication to providers at all times
• Collaborates with other departments and outside agencies to meet identified needs of the providers and their patients, while also ensuring credentialing staff cooperation
• Works well in a team environment
• Maintains regular and predictable attendance
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
• Works to encourage and promote Company culture throughout the organization
• Other duties as may be assigned

Qualifications:

• Requires a high school diploma or its equivalent
• Ability to learn quickly and be self-motivated
• One to three years' general work experience
• Minimum of one year of health plan experience preferred
• Familiarity with insurance terms and concepts
• Intermediate skill with Microsoft Excel and Word
• Knowledge of credentialing process a plus

Physical Requirements:

Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

Benefits:

• 401K (4% Match, Immediate Vesting)
• Accident insurance
• Competitive salary
• Critical Illness Insurance
• Dental Insurance
• Employee Assistance Program
• Flexible Spending Account
• Health & Wellness Program
• Health Savings Account
• Life & AD&D Insurance
• Long Term Disability
• Medical Insurance
• Paid Time Off
• Pet Insurance
• Short Term Disability
• Vision Insurance

Pre-Employment Screening:

Drug Screen and Background Check Required

HealthOne is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.