CLAIMS AND CREDENTIALING ANALYST
About The Position
The Claims and Credentialing Analyst analyzes and coordinates Provider Data team activities by evaluating and refining processes, conducting data analysis, ensuring compliance with applicable state, CMS, and contractual guidelines, and supporting provider compliance with credentialing standards. The role coordinates credentialing and re-credentialing, investigates delays and enrollment issues, verifies provider information, maintains accurate records and databases, and prepares materials for Credentialing Committee review. The position also performs provider claims and capitation payment analysis, reviews claims for adjudication by the Third-Party Administrator according to contracts and authorizations, coordinates with Finance on provider payments and payment adjustments, and develops provider performance scorecards. It prepares data for regulatory and internal inquiries and provides productivity and issue reports to management. The stated schedule is 8:30 a.m. to 5:30 p.m., 40 hours per week.
Requirements
- Bachelor’s degree and/or equivalent work experience.
- At least 3 years of credentialing experience.
- Proficiency with Microsoft Office, including Excel, Outlook, and Word.
- Strong organization, multitasking, problem-solving, and time-management skills.
- Ability to review and draft correspondence using email and word-processing systems.
- Professional, friendly, and effective communication skills.
- Ability to meet the listed physical requirements, including standing, sitting, lifting/pushing/pulling up to 50 pounds, bending or squatting, using stairs and walking, operating equipment, reading and writing accurately, listening and speaking clearly, and applying sound judgment and analysis.
Nice To Haves
- Credentialing experience in a health plan setting.
- Certified Provider Credentialing Specialist certification.
Responsibilities
- Coordinate provider credentialing to improve efficiency and meet deadlines.
- Research and resolve credentialing and re-credentialing delays and enrollment issues in a timely manner.
- Manage confidential information for internal staff, including physicians and nurse practitioners.
- Review and verify demographic updates for processing.
- Keep the database accurate and current.
- Maintain logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing.
- Prepare documents for Credentialing Committee review.
- Contact providers to verify information and respond to miscellaneous inquiries, including provider portal access, nursing home documentation, and medical records retrieval.
- Conduct in-depth provider claims analysis using multiple data sets, perform root cause analysis, and drive process improvements for measurable outcomes and operational efficiency.
- Collect and prepare data for state, federal, and internal inquiries while ensuring accuracy and regulatory compliance.
- Coordinate with Finance on check runs and provider payments, including refunds, overpayments, and underpayments.
- Review and investigate claims for adjudication by the Third-Party Administrator, applying contractual provisions in accordance with provider contracts and authorizations.
- Review monthly capitation payments for compliance with contractual obligations.
- Analyze capitation payments for trends and discrepancies and identify process improvements.
- Develop monthly provider performance scorecards and work with stakeholders to assess contractual compliance and improvement areas.
- Provide productivity and issue reports to Management.
- Stay current on policies affecting provider credentials and enrollment processes.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
