Credentialing and Network Coordinator

4 weeks ago

Houston, United States Apex Health Solutions Full time
Description

Summary:

The Credentialing and Network Coordinator will be responsible for ensuring the data integrity for our contracted providers and facilities. This includes conducting ongoing auditing of the departments' database, monitoring regulatory agencies requirements, participation status with payer programs, and other demographic, credentialing, and contractual requirements. The Credentialing and Network Coordinator will also be responsible for timely and accurate reporting to senior management, health plan and other business partners on regular bases. In addition, responsibilities include supporting the Network Operations team with data analysis and integrity. This individual is also responsible for research, analysis and maintenance of payer contracts, provider database and database loads, provider participation roster, performance reports and evaluations of data quality and integrity.

Essential Functions and Responsibilities:
  • Collaborate and oversee credentialing workflow.
  • Create and Maintain a Performance Dashboard outlining specific measurements related to credentialing.
  • Conduct regular analysis and audits on data across the department's multiple processes. I.e., Credentialing and Provider Data Management workflows.
  • Ensure rosters and credentialing delegation agreements are compliant. I.e., timely, executed correctly.
  • Manage data audits with payers and contracted groups and delegates.
  • Participate in ongoing department process improvement initiatives, with a focus on continuous improvement of standard processes, policies and procedures.
  • Collaborate with staff, business units and health plan partners to identify and meet data reporting needs; initiate meetings and conversations to resolve discrepancies.
  • Create new provider rosters and reconcile existing provider rosters for health plans and other business partners.
  • Leverage knowledge and expertise of reports to develop and implement dashboards and maps for multiple audiences.
  • Develop and document standards, policy and procedures for data entry and network operations data flow.
  • Responsible for various special projects and ad-hoc reports as needed.


Education and Experience
  • Bachelor's degree in Business, Data Analytics, Healthcare Administration or related field; or, an equivalent combination of education and/or experience minimum three (3) years of experience in a directly related role in the healthcare industry.
  • Proficiency with Microsoft Office applications (including Excel) and web-based technologies.
  • Excellent verbal, written and interpersonal communication skills; highly collaborative team approach to work.
  • Successful record of managing multiple projects with demonstrated ability to work independently in rapidly-changing environments.


Skills:
  • Experience with Health Plan Credentialing Delegation Audits.
  • Ability to research and analyze data.
  • Ability to delegate work and measure credentialing performance.
  • Highly attentive to detail and strong organizational skills.
  • Strong written and verbal communication.
  • Experience with provider databases and provider data management.
  • Knowledge of payer, provider and employer contracts including various payment alternatives such as fee-for-service, capitation, global budget and performance compensation.
  • Knowledge of the National Committee for Quality Assurance (NCQA), health plan employer data.
  • Knowledge of Utilization Review Accreditation Commission (URAC), CVO credentialing and case management.
  • Experience with database management in a healthcare setting.
  • Excellent problem-solving skills, including the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
  • Able to present complex or technical information in a clear concise manner to audiences with varying levels of technical understandings.


ABOUT APEX HEALTH SOLUTIONS

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex's unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex's experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.

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