Credentialing Representative

Health One Alliance•Dalton, GA

About The Position

The Credentialing Representative is responsible for the credentialing and recredentialing of providers in compliance with NCQA, CMS, DOI, state credentialing standards and HealthOne Alliance policies and procedures. This includes entering data, performing appropriate credentialing verifications, preparing, and presenting at Credentialing Committee Meetings, preparing for Board of Directors reviews and notification of the completed credentialing process. This role will assist in the monitoring of license expirations and status changes and take action when appropriate. The position also helps to review and update criteria and credentialing policies and procedures, as necessary, but no less than annually.

Requirements

Requires a high school diploma or its equivalent
Ability to learn quickly and be self-motivated
One to three years’ general work experience
Familiarity with insurance terms and concepts
Intermediate skill with Microsoft Excel and Word
Drug Screen and Background Check Required

Nice To Haves

Minimum of one year of health plan experience preferred
Knowledge of credentialing process a plus

Responsibilities

Works directly with providers to ensure all necessary credentialing information has been received prior to beginning the credentialing process
Provides timely follow-up to obtain required documentation to complete the credentialing process
Enters provider data into appropriate data management systems
Performs all credentialing verifications necessary to complete the credentialing process while maintaining the appropriate compliance standards in an electronic format
Prepares and presents providers records for Credentialing Committee Review
Prepares Credentialing Committee recommendations for Board of Directors review
Notifies providers of credentialing decisions within compliance timeframes
Assists providers with all questions related to provider credentialing
Performs provider re-credentialing, at least every 36 months in compliance with NCQA standards
Assists with ensuring providers are compliant with the NCQA, CMS, DOI and state requirements regarding availability and access standards and evaluates the standards to ensure they address the requirements outlined by NCQA, CMS, DOI and state
Ability to take direction and quickly adapt to changing guidelines and standards
Assists with preparing credentialing files for delegation audits
Assists in monitoring of license expirations and status changes in LEMM and takes action when appropriate
Assists in reviewing and updating criteria and credentialing policies and procedures, as necessary, but no less than annually
Educates providers and the Provider Relations regarding criteria and credentialing policies and procedures when necessary
Works with Network Management to ensure providers’ initial information and updates are sent for processing timely and accurately
Assists Network Management and Provider Relations with changing a provider from a direct relationship to delegated relationship
Maintains provider and patient confidentiality at all times
Provides positive, supportive, communication to providers at all times
Collaborates with other departments and outside agencies to meet identified needs of the providers and their patients, while also ensuring credentialing staff cooperation
Works well in a team environment
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned