Location: Rockledge,FL, USA
* Fully Remote position
POSITION SUMMARY
The Provider Network Credentialing Specialist is responsible for coordinating, monitoring and maintaining the credentialing and re-credentialing processes of health care providers and practitioners to ensure they meet the requirements of the Health Plan credentialing policies and regulatory agencies including the National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS) standards.
PRIMARY ACCOUNTABILITIES
* Follow the Health Plan's credentialing processes and meets all regulatory and accreditation requirements and works with on-site NCQA, HEDIS and CMS auditors as needed.
* Provide reports to internal departments for annual projects/audits such as HEDIS Roadmap, QI Credentialing Evaluation and Finance as well as reports for the Medical Director, Credentialing Committee and the Board of Trustees.
* Perform precise entry of provider information to ensure accurate provider directories and overall data integrity.
* Responsible for conducting primary source verification on applicants which may include but not limited to, request, investigation, verification, tracking, and follow-up of primary responses from all required sources as required by the Health First credentialing policies and procedures.
* Act as liaison with providers and facilities to assist with credentialing issues and ensure that demographic information is received and entered in the system correctly while communicating with providers on the status of their credentialing, as well as any findings during the credentialing process.
* Conduct on-going monitoring of practitioners and organizational providers to identify important quality and safety issues in a timely manner.
* Manage confidential files on all credentialed practitioners and organizational providers.
* Use web-based and other available tools to oversee AHCA site visits and findings, as well as accreditation status for organizational providers.
* Conduct reviews of provider network adequacy for quality improvement evaluation, the National Committee for Quality Assurance, meeting standards to the Centers for Medicare & Medicaid Services Central and Regional Offices as well as the various departments within the Office of Insurance Regulation for service area expansion efforts, as needed.
* Participate as needed in the provider term letter process, including all member communication related to provider terminations.
* Serve as credentialing information source for the Health Plan and Health First Health system.
* Conduct Provider Directory accuracy audits and participates in any meetings, projects and sub-teams related to the Provider Directory to ensure provider information is accurate for the Provider Directory.
MINIMUM QUALIFICATIONS
* Education: Associate's degree.
* Licensure: None
* Certification: None
* Work Experience: Two years' experience with physician and/or organizational credentialing processes.
* Work Experience in lieu of Education: None
* Knowledge/Skills/Abilities:
* Exceptional interpersonal, communication and organizational skills.
* Excellent organization skills required.
* Advanced technical skills for use of MS Office (Excel, Word, Outlook and PowerPoint).
* Strong time-management skills.
* High degree of accuracy, efficiency and dependability.
PREFERRED QUALIFICATIONS
* Education: Bachelor's degree
* Licensure: No additional
* Certification: No additional
* Work Experience: No additional
* Knowledge/Skills/Abilities: No additional
PHYSICAL REQUIREMENTS
* Majority of time involves sitting or standing; occasional walking, bending, stooping.
* Long periods of computer time or at workstation.
* Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
* May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
* Communicating with others to exchange information.
* Visual acuity and hand-eye coordination to perform tasks.
* Workspace may vary from open to confined; on site or remote.
* May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.