Delegated Credentialing Specialist

Job Description

Job Description

Overview

The Delegated Credentialing Specialist is responsible for supporting multiple specialty areas of business operations surrounding delegated credentialing, and will execute the strategic business plan as well as lead the day-to-day functions and staff.

This position will provide reporting, implementation support, and manage the monitoring of programs for services delivered through contracted, delegated entities (This position is instrumental in facilitating delegation program activities to ensure alignment with NAH strategies, goals, and objectives.

Responsibilities

Essential Job Functions

• Adhere to NCQA guidelines.
• Audit Provider Licensure Files to NCQA guidelines.
• Pull On-Going Files in accordance to NCQA.
• Understanding of Initial and Re-Credential Delegated files.
• 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.
• Ongoing interaction with payers.
• Assist offices and internal departments with credentialing issues.
• Must be able to utilize the licensure portals.
• Source for effective dates from the payers.
• Notify relevant parties of effective dates.
• Keep records in licenses, credentials and insurance contracts.
• Responsible for all insurance changes.
• Respond to payers in a timely manner.
• Responsible for tracking provider renewals.
• Assess Monthly / Quarterly payer Directory updates.
• Communication with providers as needed.
• Rewrite policy and procedures
• Responsible for ensuring thorough preparation of documentation, reports, and any other information needed for regulatory and NCQA audits related to delegation oversight.
• Confirm delegated provider credentialing audits performed by the delegated credentialing team for initial, annual, and interim assessments in accordance with Joint Commission, NCQA, CMS, state and federal requirements
• Ensure NAH delegated credentialing process meets provider customer expectations using reports and trend analysis.
• Ensure annual delegated credentialing audit timeliness and corrective action plans are met. 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
• Other projects as assigned.

Compliance and Safety

• If required for position, ensures all certifications and / or licenses are up-to-date and valid prior to expiration dates.
• Completes all company mandatory modules and required job specific training in the specified time frame.
• Responsible for reporting any safety related incident in a timely fashion through the Midas / RDE tool; attends all safety related training programs;

performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

Responsible for maintaining up-to-date knowledge of cybersecurity trends, developments, best practices and regulatory changes.

Qualifications

Education

High School Diploma required.

Certification & Licensures

Certified Provider Credentialing Specialist (CPCS) preferred.

Experience

• 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.
• Must be able to function with minimal supervision and be able to prioritize all work tasks.
30+ days ago