Credentialing Specialist I - 003227 at Excellus Health Plan Inc. in Plattsburgh, New York

Job Description:

This position reviews and source verifies all initial and re-credential provider applications for designated health care professionals for the purpose of determining adherence to the Health Plan Credentialing Policies. The Specialist communicates with all state, federal and other regulatory agencies to obtain and/or validate information submitted by providers. The incumbent researches and investigates all issues involved in the credentialing/re-credentialing process. This position prepares findings and recommendations for the Medical Director to present to the Health Plan Credentialing Committee. This position conducts follow-up on Credentialing Committee decisions and requests for further investigation. Reviews, maintains and updates credentialing database as appropriate.

Essential Responsibilities/Accountabilities
Level I
• Under the direction of the department supervisor, credentials and re-credentials all applicants
and explains the application procedures to prospective applicants, including facilities.
• Reviews all new applicants for adherence to the Health Plan Credentialing requirements; Initiates the re-credentialing process according to protocols. Documents source verification in the credentialing protocols, as required.
• Investigates and verifies the continuing adherence of all participants to the Health Plan Credentialing protocols, NCQA Standards, and Federal and State requirements.
• Collects data and prepares all delegated providers for internal review and approval.
• Examines all applications for discrepancies with the Health Plan procedures, policies and system requirements. Investigates, verifies and documents the accuracy of statements made on the application.
• Prepares all applicants and re-applicants for review with appropriate recommendations. Be prepared to present all recommendations with supporting statements to the Health Plan Medical Director and required Committee(s) Members, as needed.
• Responds to requests made by the Credentialing Supervisor for further research, confirmation and investigations of providers and specialty qualifications.
• Notifies new and recredentialed applicants of decisions made by the Health Plan Credentialing Committee.
• Investigates and examines all requests for changes made by participants at the time of recredentialing. Communicates all changes to the appropriate departments.
• Within a three year period, investigates and verifies the continuing adherence of all participants to the Health Plan Credentialing protocols, NCQA Standards, and Federal and State requirements.
• Monitors Federal and State reports for sanctions regarding all new and recredentialed providers. Notifies the Supervisor and corporate divisions, as appropriate.
• Coordinates the termination of all the Health Plan credentialed providers.
• Communicates with providers regarding issues relating to the providers applications. Works with providers to resolve credentialing issues.
• Attends meetings as directed by the Supervisor.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II - performs all functions as noted in level I, in addition to:
• As requested, may be responsible for moderating meetings with appropriate physicians and consultants for the purpose of establishing or revising the Health Plan Credentialing Requirements and facilitates the approval and implementation of those protocols.
• Supports the Corporate Quality Improvement Program through participation on quality teams. Continuously works to identify and remove barriers to increased productivity, quality, cost effectiveness, and timeliness of operations and customer satisfaction.
• Participates in new hire training as directed by management.
• Assists in file audits of delegated entities; reviews delegated credentialing policies to assure they meet NCQA, Federal and State requirements.
• Independently organizes and prepares agendas and minutes for the Corporate Credentialing Committee.
• Assists in the hearing appeal process; arranging hearing dates and organizing/preparing hearing packets.
• Assists in interviewing process of candidates applying for open positions.
• Leads onboarding and training process for new hires and provides mentoring.
• Works independently within the team as a subject matter expert to teammates and other departments.
• Monitors monthly expiration reports.
• Interfaces with external regulatory auditors, as needed.
• Assists Supervisor with internal file audits.
• Assists with the implementation, revisions and documentation of workflow processes and/or policies.

Minimum Qualifications
NOTE:
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels
• A.A.S. degree or minimum of two years experience working with physicians and/or a Health Plan environment.
• Knowledge of physician training procedures preferred, in addition to an understanding of the provider database and health plan liability issues.
• Ability to communicate with health care professionals in a professional manner.
• Excellent oral and written skills are essential.
• Must have ability to travel to the regional offices occasionally when needed.
• Must have working knowledge of PC Software application products, such as Microsoft Office and the ability to work within established databases.
• Strong interpersonal skills with the ability to work in a team environment.

Level II - in addition to Level I Minimum Qualifications:
• Ability to develop in-depth problem/issue analysis with written and oral presentation of findings.
• Works effectively in a team environment
• Minimum of three years' experience working within credentialing team or related experience.
• Proficiency in analyzing or obtaining data
• Demonstrates a professional demeanor in dealing with all levels of management, other departments, customers and peers.
• Demonstrates flexibility and adaptability to changing work assignments and the introduction of new technology and procedures.
• Effectively performs major or minor tasks with minimum direction.
• Proficient and knowledgeable in presentation, quoting and enforcing credentialing, NCQA, Federal and State requirements.
• Demonstrates a strong working knowledge of the entire provider enrollment and re-credentialing process.
• Skilled in additional applications beyond core credentialing system (i.e. iFacets, Contract Manager).
• Demonstrates a positive attitude toward accepting new assignments and learning new systems.

Physical Requirements
• Ability to bend, lift, carry and move files as needed on a monthly basis. Includes some overhead work.

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The Lifetime Healthcare Companies aim to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer