Credentialing Operations Specialist
2 weeks ago
Position Summary
The Credentialing Operations Specialist plays a crucial role in supporting various specialty areas of business operations related to delegated credentialing. This role involves executing strategic business plans and overseeing daily functions and staff management. The specialist will provide essential reporting, implementation assistance, and manage the oversight of programs for services delivered through contracted delegated entities. This position is vital in facilitating delegation program activities to ensure alignment with the organization's strategies, goals, and objectives.
Key Responsibilities
Core Functions
* Ensure compliance with NCQA standards.
Conduct audits of provider licensure files to adhere to NCQA guidelines.
Manage ongoing file reviews in accordance with NCQA requirements.
Demonstrate understanding of initial and re-credentialing delegated files.
Handle delegated credentialing submissions to payers.
Prepare and distribute applications for facilities and providers to payers.
Coordinate, monitor, and maintain all credentialing and re-credentialing processes.
Upload and update documentation in the system as necessary.
Engage in ongoing communication with payers.
Assist internal departments and offices with credentialing inquiries.
Utilize licensure portals effectively.
Source effective dates from payers and notify relevant parties.
Maintain accurate records of licenses, credentials, and insurance contracts.
Manage all insurance-related changes.
Respond promptly to payer inquiries.
Track provider renewal timelines.
Assess monthly and quarterly updates to payer directories.
Communicate with providers as needed.
Revise policies and procedures as required.
Ensure thorough preparation of documentation, reports, and any necessary information for regulatory and NCQA audits concerning delegation oversight.
Confirm that delegated provider credentialing audits are conducted by the delegated credentialing team for initial, annual, and interim assessments in compliance with relevant standards.
Ensure that the delegated credentialing process meets provider customer expectations through reports and trend analysis.
Oversee the timeliness of annual delegated credentialing audits and corrective action plans. Manage credentialing rosters, reports, and compliance for delegated providers.
Act as a liaison between delegated providers and internal partners.
Assist in negotiating delegated agreements.
Maintain a comprehensive understanding of regulatory credentialing requirements.
Participate in additional projects as assigned.
Compliance and Safety
* Ensure all necessary certifications and licenses are current and valid prior to expiration.
Complete all mandatory training modules and job-specific training within the designated timeframe.
Report any safety-related incidents promptly through the appropriate channels; attend all safety training programs; perform work safely; monitor the work environment for potential safety issues and ensure compliance with safety practices.
Stay informed about cybersecurity trends, developments, best practices, and regulatory changes.
Qualifications
Education
* High School Diploma is required.
Certification & Licensures
* Certification as a Provider Credentialing Specialist (CPCS) is preferred.
Experience
* A minimum of 2-3 years of experience in healthcare credentialing is required, with CPCS certification preferred.
* Experience in health plan delegation is preferred.
* Strong verbal and written communication skills are essential.
* Must be well-organized and detail-oriented with the ability to manage multiple tasks effectively.
* Proficiency in Microsoft Office applications, including Word and Outlook, is required.
* Ability to work independently with minimal supervision and prioritize tasks efficiently.
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