Credentialing Advisor

Primary Job Duties and Responsibilities:

• Manages health plan requests, audits, and delegated credentialing programs to maintain positive relationships between the health plan, physician, providers, and practice managers. 
• Leads credentialing efforts, providing expert guidance on all provider credentialing projects. Supports and provides direction to other members of the team. Exercises considerable creativity, foresight, and judgment in conceiving, planning, and delivering initiatives.
• Focuses on providing thought leadership within Credentialing but works on broader projects as well, which requires understanding of the wider business.
• Maintains all credentialing and re-credentialing policies and processes and ensures that they are in compliance with NCQA and all applicable state regulations. Seeks out identification of process improvement opportunities.
• Completes day-to-day Network Operations, such as roster management and physician panel maintenance without immediate supervision, but has ready access to advice from more experienced team members. 
• Works cross-functionally, focusing on ensuring short-term outputs and the effectiveness of team integration with other parts of the organization.
• Maintains a professional, positive work environment that promotes high performance. 
• Acts as a subject matter expert on credentialing responsibilities and network relationship management.
• Coordinates all aspects of credentialing, including initial appointment, reappointment, and privileging. Responsible for data administration for medical staff credentialing software and databases.
• Implements and monitors the procedures for the credentialing or re-credentialing of physicians and/or providers.
• Tracks delegation oversight activity and re-credentialing activity and corrective actions. Documents peer review activities and materials.
• Performs or supports on site state and internal audits.
• Coordinates credentialing reporting systems to monitor credentialing/re-credentialing activity, delegation oversight, vendor management, sanction monitoring and facility credentialing/re-credentialing activities.
• Partners with Provider network contracting in negotiating contracts with delegated vendors.
• Manages data preparation and assists with development of recommendations for credentialing committee review and approval.
• Works autonomously, only requiring “expert” level technical support from others.
• Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures.
• Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Credentialing and data, and provides expertise in statistical analysis and quantitative processes.
• Resolves non-routine issues escalated from more junior team members.

Education and Minimum Requirements:

• Associate Degree in Medical Staff Service Science or other AA Degree in business. Or a related field of study or an equivalent combination of training and experience.
• Five years recent experience in medical staff services field including extensive credentialing, privileging and roster management experience.
• Strong leadership capabilities, including leading projects and process improvement efforts, while leading through influence.
• Ability to work independently with limited supervision as well as collaborate within the broader Quality team and Evernorth Care Group organization.
• Ability to effectively interact with all levels of the organization Knowledge of state/federal and NCQA regulatory requirements.
• Have excellent customer service skills, time management, organization skills and communication skills.