Credentialing Coordinator - BioPlus Specialty Pharmacy

Elevance Health•Durham, NC

2d•Hybrid

About The Position

The Credentialing Coordinator coordinates and leads credentialing program-level compliance activities for the sanction monitoring program, delegation oversight audits and/or regulatory and compliance audits. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Requirements

Requires a BA/BS degree in a related field and minimum 5 years credentialing experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Strongly preferred credentialing certification.

Responsibilities

Performs oversight of credentialing and re-credentialing activities and processes, including internal and external audits.
Responsible for account management of contracted organizations.
Acts as a liaison to delegates and credentialing vendors to ensure that credentialing program compliance requirements are maintained.
Monitor contract compliance and coordinates/negotiates contractual language changes when required.
Coordinates all compliance filings of credentialing specific documents and policies.
Coordinates and conducts initial, annual and focused (corrective action plan) audits, including vendor and/or delegation oversight, or department audits.
Provides feedback and recommendations to improve processes and performance.
Resolves issues independently specific to delegation oversight, sanction monitoring, validation, notification, system configuration and reporting, and credentialing policy and procedural reviews and exceptions.
Serves as corporate contact and interface with internal business partners on problems, resolutions, questions, and regulatory or accreditation audits.
Provides process oversight of daily business operations as it relates to resolution of non-responsive providers to credentialing and re-credentialing.
Maintains delegation/credentialing standards and business requirements.
Researches and resolves delegated credentialing-related issues.
Provides recommendations to committee on process administration.
Reviews assigned Health Plan elements in Credentialing Manual and provides updates as appropriate regarding new or improved documentation resources and business rules.
Leads special projects