Job Description
MISSION
Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.
VALUES
HealthOne is guided by a cultural framework that embodies our values and drives our decisions.
Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.
HealthOne seeks individuals with integrity and heart to embody our values. Whether you're starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.
JOB PURPOSE
The Credentialing Specialist 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.
ESSENTIAL JOB DUTIES
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
Assesses environments for safety hazards which could harm patients, visitors, or other provider employees and reports hazards to appropriate supervisors
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
QUALIFICATIONS
High School Diploma or Equivalent
College coursework in business, health administration or related field preferred
One to three years' general work experience
Minimum of one year of health plan experience preferred
Familiarity with insurance terms and concepts
Intermediate skill with Microsoft Excel and Word
Broad-based business experience within the healthcare/managed care environment
PHYSICAL REQUIREMENTS
Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.
BENEFITS
401K (4% Match, Immediate Vesting)
Accident insurance
Competitive salary
Critical Illness Insurance
Dental Insurance
Employee Assistance Program
Flexible Spending Account
Health & Wellness Program
Health Savings Account
Life & AD&D Insurance
Long Term Disability
Medical Insurance
Paid Time Off
Pet Insurance
Short Term Disability
Vision Insurance
PRE-EMPLOYMENT SCREENING
Drug Screen and Background Check Required
HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.
Job Tags
Temporary work, Work experience placement, Immediate start, Flexible hours, Night shift,