Credentialing Specialist

Credentialing Analyst

Credentialing Analyst supports the credentialing program that implements federal, state and local regulatory and NCQA accreditation requirements. Ensures that all practitioners and facilities are evaluated upon entry into the network and conducts an ongoing review of the providers. Gathers, analyzes, and report provider data for the provider directory, billing needs, and member support. Communicates with providers and provider groups to answer their questions and concerns or direct to the proper department. Assists with oversight audits of delegated and non-delegated providers. Responsibilities include building and maintaining relationships with external vendors and credentialing partners including Aperture & Texas Association of Health Plans. Administers reports in external database portals & analyzes data, confirms accuracy, and presents to internal department. Assists with the oversight of the delegated and non-delegated provider and facility's data. Gathers, analyzes, and reports provider data to internal and external customers. Ensures that all practitioners and facilities are evaluated upon entry into the network and conducts an ongoing review of the providers. Identifies opportunities for improvement through the audit process and provide recommendations. Accurately tracks, reports, and follows up on the status of credentialing applications. Maintains a strict degree of confidentiality in all areas relating to provider credentials, status and provider personal information. Familiar with state specific all credentialing department policies and procedures. Assist with miscellaneous audits projects throughout the year as required. Communicates with Credentialing Manager regarding any or all credentialing delays or issues. Other duties as assigned.

Job Accountabilities include identifying ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.

Skills or Special Abilities include advanced proficiency in Microsoft Excel to include Vlookup, creating complex function and equations. Strong interpersonal, problem solving and relationship building skills with positive attitude and demeanor. Ability to take initiative to research and form conclusions independently. Ability to manage multiple deadlines and time constraints in a fast-paced environment. Demonstrated ability to collaborate effectively and work as part of a team including internal and external stakeholders. Ability to perform detail work efficiently and with a high degree of accuracy. Clear and professional verbal and written communication skills with the ability to clearly explain complex processes. Skilled in interpreting, analyzing, and providing recommendations regarding data accuracy and data collection needs and processes. Excellent planning, organization, time management, and documentation skills.

Submission Requirements include 3+ years of managed care or credentialing analyst experience. Proficiency in Adobe Pro, Microsoft Outlook & SharePoint required. Experience with CAQH, Texas Association of Health Plans (TAHP), NCQA accreditation, Aperture, or National Provider Data Bank (NPDB) is strongly encouraged. Experience with federal, state and/or local managed care statutes is preferred. Experience with managing provider data is preferred. National Association Medical Staff Services (NAMSS) certificate -- strongly preferred. Bachelor's degree required; healthcare, business, administration. Profile Requirements include Resume/Work history Skills Checklist - analyst, compliance/credentialing, Microsoft/IT Copy of Certification(s) At least 1 reference Active Driver License