Delegated Credentialing Specialist

2 weeks ago

Flagstaff, Arizona, United States Northern Arizona Healthcare Corporation Full time
Job Title: Delegated Credentialing Specialist

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 and ensure timely processing.
  • 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 seamless communication.
  • Assist offices and internal departments with credentialing issues.
  • Utilize licensure portals effectively.
  • 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 using reports and trend analysis.
  • 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.
  • Perform other projects as assigned.

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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