CLAIMS AND CREDENTIALING ANALYST

C2Q Health Solutions•New York, NY

4d•Onsite

About The Position

The Claims and Credentialing Analyst will be a pivotal role in analyzing and coordinating all activities of the Provider Data team by evaluating and refining processes, conducting comprehensive data analysis, and ensuring compliance with all applicable State, CMS, contractual guidelines and ensuring provider compliance with credentialing standards.

Requirements

Bachelor’s Degree, and/or equivalent work experience.
A minimum of three (3+) years of credentialing experience.
Microsoft Office/Suite Proficient (Excel, Outlook, Word, etc.)
Highly Organized.
Able to multitask efficiently and effectively.
Solid problem solving and time management skills.
Have the ability to review and draft correspondence in email and word processing systems.
Professional, Friendly, and Skillful Communication Skill Set.

Nice To Haves

Credentialing in a Healthplan setting.
Certified Provider Credentialing Specialist

Responsibilities

Coordinate provider credentialing process to increase efficiency and ensure that credentialing deadlines are met.
Research and solve credentialing/re-credentialing delays & issues with enrollment in a timely manner.
Manage confidential information of internal staff (Physicians, Nurse Practitioners).
Ensure demographic updates are reviewed and verified for processing.
Ensure the database is kept accurate and updated.
Maintain necessary logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing to ensure requirements are met in a timely manner.
Prepare documents for Credentialing Committee review.
Outreach to provider for information verification and miscellaneous inquiries, i.e. provider portal access, nursing home documentation, medical records retrieval, etc.
Perform in-depth provider claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency.
Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements.
Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments.
Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.
Review monthly capitation payments in accordance with contractual obligations.
Perform analysis on capitation payments to determine trends or discrepancies on the payments as well as determine improvements on the process.
Prepare analysis on network provider performance through the development of monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirement and identify areas for improvement.
Provide productivity and issues reports for Management.
Remain current on policies affecting provider credentials and enrollment processes.
Other duties as assigned.