Credentialing Specialist III Job in Nashville, Tennessee US

Credentialing Specialist III

Job ID: 2012-17988
# Positions: 1
Location: US-TN-Nashville
Type: Regular Full-Time

Summary:

JOB SUMMARY: Coordinates completion of provider credentialing process for identified segment of health plan credentialing needs. Performs provider credentialing and recredentialing, and delegated provider credentialing for assigned Health Plan(s). May provide guidance to Credentialing Specialists I and II on more complex credentialing issues.

Responsibilities:

PRIMARY RESPONSIBILITIES: 1. Manages provider or delegated provider credentialing process to meet time-sensitive deliverables, including notification and follow up of other departments directly involved in oversight. Reviews provider's policies and procedures; performs on-site review of physical plant, and review of program in its entirety including adherence to AMERIGROUP's delegation program requirements; audits credentialing and recredentialing files. 2. Evaluates and analyzes provider's credentialing program to ensure compliance with AMERIGROUP, federal, state, NCQA, AAAHC requirements; determines delegate's opportunities for improvement and recommends denial or revocation of the decision to delegate when compliance issues arise that compromise AMERIGROUP's ability to maintain contractual or state requirements. 3. Works independently with internal and external customers to research and resolve credentialing-related issues. 4. Communicates with physicians and their office staff, IPA's, hospitals and other provider organizations to provide primary source verification. Maintains relationships with delegate, delegate's office personnel, Legal, Regulatory and Health Plan's Provider Relations department to provide and/or obtain documentation pertinent to timely and accurate completion of the delegated credentialing process. 5. Provides process oversight of daily business operations as it relates to resolution of non-responsive providers to credentialing and recredentialing to ensure all efforts are made to keep providers in compliance according to NCQA/AAAHC standards and regulatory requirements. 6. Coordinates annual delegation assessment and onsite visit, on-going monitoring, audit preparation, and credentialing committee preparation and reporting. 7. Tracks progress of working files to ensure submission to Credentialing Committee in a timely manner, to meet department Service Level Agreements. Coordinates the transfer of files ready for Committee review to the Health Plan on a weekly basis. 8. Maintains delegation/credentialing standards and business requirements (policy review) - NCQA, AAAHC. Researches and resolves delegated credentialing-related issues, including review of draft delegation addenda's from the Legal department to determine whether draft revisions may create compliance issues for AMERIGROUP. Provides recommendations to committee on process administration. 9. Maintains repository of delegated entities information, including audit results, narratives, credentialing committee notification, corrective action plan and any pertinent documents gathered in the ongoing monitoring process. 10. Coordinates with Health Plan and Provider Data Management regarding staff roster submission of new practitioners, changes to existing practitioners or provider terminations/dismissals. 11. Coordinates with Health Plan regarding termination process of any delegate who fails to maintain the delegation requirements set forth by AMERIGROUP to credentialing and recredentialing in compliance according to NCQA, AAAHC and CMS standards and regulatory requirements. 12. Leads biweekly Credentialing Department/Health Plan conference calls. 13. Reviews all licensing agency and Medicare/Medicaid sanction sites and communications on a monthly basis, reporting any findings to department management and Health Plan. 14. Supports the credentialing portion of annual state audits and ensures the submission of review materials as requested.

Qualifications:

Education Required: - High School Preferred: - Bachelor's degree Years and Type of Experience Required: Required: - Minimum 4 years' experience using computer systems in an administrative setting - Minimum 3 years' credentialing experience in another environment, or 2 years' progressive credentialing experience with AMERIGROUP Preferred: - Experience leading a team to meet quality and productivity goals. Specific Technical Skills Required: - Proficient in MS Office, including but not limited to Word, Excel - Must be able to pass Credentialing Proficiency Test prior to expiration of initial 90 day period and on an annual basis.

Required: CPCS - Certified Provider Credentialing Specialist or CMSC - Certified Medical Staff Coordinator Other: Required: - Excellent verbal and written communication skills - Strong attention to detail - Strong organizational skills - Appreciation of cultural diversity - Maintains a positive demeanor, actively participate in team/department meetings and assist the department in identifying areas of opportunity while assisting in driving solutions - Ability to interact with all levels of management - Ability to set priorities and manage multiple demands effectively minimal direction and oversight. PHYSICAL REQUIREMENTS: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. - Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices. - Ability to communicate both in person and/or by telephone. - Must be able to travel up to 60% of the time and adhere to AMERIGROUP travel policies and procedures - Occasional lifting up to 25 lbs. - Must be available for overtime as needed

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