Delegated Credentialing Specialist
3 weeks ago
Job Summary:
The Delegated Credentialing Specialist will play a crucial role in supporting multiple specialty areas of business operations surrounding delegated credentialing. This position will execute the strategic business plan, lead day-to-day functions, and staff. The successful candidate will provide reporting, implementation support, and manage the monitoring of programs for services delivered through contracted, delegated entities.
Key Responsibilities:
- Adhere to NCQA guidelines and ensure compliance with regulatory requirements.
- Audit provider licensure files to ensure accuracy and completeness.
- Pull ongoing files in accordance with NCQA guidelines.
- Understand initial and re-credential delegated files, including delegated credentialing payer submissions.
- Prepare and distribute facility and provider applications to payers.
- Coordinate, monitor, and maintain all credentialing and re-credentialing processes.
- Upload and update the system with new documents.
- Engage in ongoing interaction with payers to ensure timely and accurate credentialing.
- Assist offices and internal departments with credentialing issues.
- Utilize licensure portals to manage provider information.
- Source effective dates from payers and notify relevant parties.
- Keep records of licenses, credentials, and insurance contracts.
- Responsible for all insurance changes and respond to payers in a timely manner.
- Track provider renewals and assess monthly/quarterly payer directory updates.
- Communicate with providers as needed and rewrite policy and procedures.
- Ensure thorough preparation of documentation, reports, and information for regulatory and NCQA audits.
- Confirm delegated provider credentialing audits performed by the delegated credentialing team.
- Ensure NAH delegated credentialing process meets provider customer expectations.
- Manage credentialing rosters, reports, and delegated compliance of NAH Delegated Providers.
- Communicate as a liaison for Delegated Providers and internal partners.
- Manage and assist in the negotiation of delegated agreements.
- Maintain working knowledge of regulatory credentialing requirements.
Qualifications:
- High School Diploma required.
- Certified Provider Credentialing Specialist (CPCS) preferred.
- Minimum 2-3 years' experience in Healthcare Credentialing, and Certified Provider Credentialing Specialist (CPCS) preferred.
- Experience in Health Plan Delegation, preferred.
- Excellent verbal and written communication skills.
- Well organized and detail-oriented with the ability to multi-task.
- Proficiency with Microsoft Office products, including Word and Outlook required.
- Ability to function with minimal supervision and prioritize work tasks.
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