Credentialing Operations Specialist

Avera•Sioux Falls, SD

1d•Onsite

About The Position

The Credentialing Operations Specialist is responsible for coordinating provider credentialing and enrollment activities in compliance with NCQA, state, and federal requirements. Reviews applications for accuracy and completeness, partners with providers and internal teams to resolve issues, and prepares files for Medical Director and committee review. Maintains credentialing data, supports audits, and ensures timely, compliant communication regarding provider status.

Requirements

The individual must be able to work the hours specified.
Visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Associate's Two-year college or technical school or an equivalent combination of education and experience.
1-3 years Credentialing experience, provider enrollment, provider contracting, compliance, advanced medical or administrative experience and/or training.

Nice To Haves

Bachelor's In a related field of health information/healthcare or business.
Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS)
Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)

Responsibilities

Knowledge of NCQA Credentialing standards and all applicable state and government laws regarding credentialing and applies them to the credentialing process.
Coordinates the initial enrollment and re-enrollment process for providers and facilities contracted with Avera Health Plans.
Reviews initial and reappointment credentialing applications to ensure compliance with NCQA process.
Ensures application completeness and works with providers to gather missing or incomplete information.
Reviews credentialing applications returned from the Central Verification Organization (CVO) to ensure Primary Source Verifications (PSV) were done accurately and timely, consistent with NCQA, state and federal credentialing requirements.
Accurately determines and documents clean vs red flag files.
Coordinates with Medical Director for file review of clean and red flag files.
Gathers additional information based on the Medical Directors feedback.
Assists in monthly Credentialing Committee File preparation.
Generates and sends out compliant communication to providers related to credentialing terminations, denials, and approvals consistent with Avera Health Plans policies and NCQA requirements.
Performs accurate data entry and maintains enrollment records within the credentialing system and internal databases.
Responds to applicants and current providers regarding the credentialing process and status.
Serves as a resource to internal and external clients by answering credentialing questions, conducting audits, and doing file preparation for audits.