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Credentialing Specialist III Job
Date: Mar 12, 2010
Location: Virginia Beach, VA, US
Job Description
Job Title:
Credentialing Specialist III
Job ID:
10146
Location: Virginia Beach, VA
Full/Part Time:
Full-Time
Regular/Temporary:
Regular
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Responsibilities
JOB SUMMARY:
Coordinates completion of provider credentialing process for identified segment of health plan credentialing needs. Performs provider credentialing and recredentialing, and delegated provider credentialing for assigned Health Plan(s). Obtains necessary information to credential and recredential providers utilizing all applicable National Committee for Quality Assurance (NCQA), Accreditation Association for Ambulatory Health Care (AAAHC), and Centers for Medicare and Medicaid Services (CMS) standards. Responsible for daily business operations, including resolution of non-responsive providers, coordination of site visits with Health Plan Provider Relations staff, and works with various group administrators and hospital medical staff offices to ensure successful and timely completion of the delegated credentialing, credentialing and recredentialing process. May provide guidance to Credentialing Specialists I and II on more complex credentialing issues.
PRIMARY RESPONSIBILITIES:
1. Manages provider or delegated provider credentialing process to meet time-sensitive deliverables, including notification and follow up of other departments directly involved in oversight. Reviews provider's policies and procedures; performs on-site review of physical plant, and review of program in its entirety including adherence to AMERIGROUP's delegation program requirements; audits credentialing and recredentialing files.
2. Evaluates and analyzes provider's credentialing program to ensure compliance with AMERIGROUP, federal, state, NCQA, AAAHC requirements; determines delegate's opportunities for improvement and recommends denial or revocation of the decision to delegate when compliance issues arise that compromise AMERIGROUP's ability to maintain contractual or state requirements.
3. Works independently with internal and external customers to research and resolve credentialing-related issues.
4. Communicates with physicians and their office staff, IPA's, hospitals and other provider organizations to provide primary source verification. Maintains relationships with delegate, delegate's office personnel, Legal, Regulatory and Health Plan's Provider Relations department to provide and/or obtain documentation pertinent to timely and accurate completion of the delegated credentialing process.
5. Provides process oversight of daily business operations as it relates to resolution of non-responsive providers to credentialing and recredentialing to ensure all efforts are made to keep providers in compliance according to NCQA/AAAHC standards and regulatory requirements.
6. Coordinates annual delegation assessment and onsite visit, on-going monitoring, audit preparation, and credentialing committee preparation and reporting.
7. Tracks progress of working files to ensure submission to Credentialing Committee in a timely manner, to meet department Service Level Agreements. Coordinates the transfer of files ready for Committee review to the Health Plan on a weekly basis.
8. Maintains delegation/credentialing standards and business requirements (policy review) - NCQA, AAAHC. Researches and resolves delegated credentialing-related issues, including review of draft delegation addenda's from the Legal department to determine whether draft revisions may create compliance issues for AMERIGROUP. Provides recommendations to committee on process administration.
9. Maintains repository of delegated entities information, including audit results, narratives, credentialing committee notification, corrective action plan and any pertinent documents gathered in the ongoing monitoring process.
10. Coordinates with Health Plan and Provider Data Management regarding staff roster submission of new practitioners, changes to existing practitioners or provider terminations/dismissals.
11. Coordinates with Health Plan regarding termination process of any delegate who fails to maintain the delegation requirements set forth by AMERIGROUP to credentialing and recredentialing in compliance according to NCQA, AAAHC and CMS standards and regulatory requirements.
12. Leads biweekly Credentialing Department/Health Plan conference calls.
13. Reviews all licensing agency and Medicare/Medicaid sanction sites and communications on a monthly basis, reporting any findings to department management and Health Plan.
14. Supports the credentialing portion of annual state audits and ensures the submission of review materials as requested.
15. Reviews assigned Health Plan elements in Credentialing Manual and provides updates as appropriate regarding new or improved documentation resources and business rules.
16. Monitors progress of delegation activity to ensure timely submission and recommendation to Credentialing Committee and/or Vendor Selection Oversight Committee (VSOC) in a timely manner, to meet department Service Level Agreements and to maintain compliance requirements.
17. Generates basic and ad hoc reports of providers required for review by Medical Director and Credentialing Committee, for participation with AMERIGROUP.
18. Conducts credentialing training for new associates, and refresher training for existing associates. Provides input for training materials and job aids.
19. Maintains current knowledge of state guidelines and regulatory requirements, and all business rules pertaining to assigned Health Plan. Maintains current knowledge of the credentialing process and applicable database system (Amisys, Facets, and CACTUS) changes.
20. Maintains thorough knowledge of AMERIGROUP policies & procedures, NCQA, AAAHC, CMS and other related accreditation standards, state guidelines, regulatory requirements and any/all Health Plan specific requirements.
21. Assist in development of “best practice” department policies and procedures and workflows to create and maintain replicable processes within the department.
22. Assists with the applicant review and interview process.
23. Leads special projects.
24. Other duties as assigned.
EDUCATION AND EXPERIENCE:
Education Required:
• High School
Preferred:
• Bachelor's degree
Years and Type of Experience Required: Required:
• Minimum 4 years' experience using computer systems in an administrative setting
• Minimum 3 years' credentialing experience in another environment, or 2 years' progressive credentialing experience with AMERIGROUP
Preferred:
• Experience leading a team to meet quality and productivity goals.
Specific Technical Skills Required:
• Proficient in MS Office, including but not limited to Word, Excel
• Must be able to pass Credentialing Proficiency Test prior to expiration of initial 90 day period and on an annual basis.
• Must have strong analytical skills to analyze complex situations, ability to formulate decisions and execute a plan of action.
Preferred:
• Experience using Amisys, Cactus, MS Access, Facets
Certifications or Licensures Required:
• None
Preferred:
• CPCS – Certified Provider Credentialing Specialist or CMSC – Certified Medical Staff Coordinator
Other Required:
• Excellent verbal and written communication skills
• Strong attention to detail
• Strong organizational skills
• Appreciation of cultural diversity
• Maintains a positive demeanor, actively participate in team/department meetings and assist the department in identifying areas of opportunity while assisting in driving solutions
• Ability to interact with all levels of management
• Ability to set priorities and manage multiple demands effectively minimal direction and oversight.
SCOPE INFORMATION
# Direct Reports: 0
# Indirect Reports: Typically 3 or more
Budgetary $ Responsibility: N/A
PHYSICAL REQUIREMENTS:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
• Ability to communicate both in person and/or by telephone.
• Must be able to travel up to 60% of the time and adhere to AMERIGROUP travel policies and procedures
• Occasional lifting up to 25 lbs.
• Must be available for overtime as needed.
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
------------
Email to Friend Save Job Apply Now
------------
Job Title:
Credentialing Specialist III
Job ID:
10146
Location: Virginia Beach, VA
Full/Part Time:
Full-Time
Regular/Temporary:
Regular
------------
Email to Friend Save Job Apply Now
------------
Responsibilities
JOB SUMMARY:
Coordinates completion of provider credentialing process for identified segment of health plan credentialing needs. Performs provider credentialing and recredentialing, and delegated provider credentialing for assigned Health Plan(s). Obtains necessary information to credential and recredential providers utilizing all applicable National Committee for Quality Assurance (NCQA), Accreditation Association for Ambulatory Health Care (AAAHC), and Centers for Medicare and Medicaid Services (CMS) standards. Responsible for daily business operations, including resolution of non-responsive providers, coordination of site visits with Health Plan Provider Relations staff, and works with various group administrators and hospital medical staff offices to ensure successful and timely completion of the delegated credentialing, credentialing and recredentialing process. May provide guidance to Credentialing Specialists I and II on more complex credentialing issues.
PRIMARY RESPONSIBILITIES:
1. Manages provider or delegated provider credentialing process to meet time-sensitive deliverables, including notification and follow up of other departments directly involved in oversight. Reviews provider's policies and procedures; performs on-site review of physical plant, and review of program in its entirety including adherence to AMERIGROUP's delegation program requirements; audits credentialing and recredentialing files.
2. Evaluates and analyzes provider's credentialing program to ensure compliance with AMERIGROUP, federal, state, NCQA, AAAHC requirements; determines delegate's opportunities for improvement and recommends denial or revocation of the decision to delegate when compliance issues arise that compromise AMERIGROUP's ability to maintain contractual or state requirements.
3. Works independently with internal and external customers to research and resolve credentialing-related issues.
4. Communicates with physicians and their office staff, IPA's, hospitals and other provider organizations to provide primary source verification. Maintains relationships with delegate, delegate's office personnel, Legal, Regulatory and Health Plan's Provider Relations department to provide and/or obtain documentation pertinent to timely and accurate completion of the delegated credentialing process.
5. Provides process oversight of daily business operations as it relates to resolution of non-responsive providers to credentialing and recredentialing to ensure all efforts are made to keep providers in compliance according to NCQA/AAAHC standards and regulatory requirements.
6. Coordinates annual delegation assessment and onsite visit, on-going monitoring, audit preparation, and credentialing committee preparation and reporting.
7. Tracks progress of working files to ensure submission to Credentialing Committee in a timely manner, to meet department Service Level Agreements. Coordinates the transfer of files ready for Committee review to the Health Plan on a weekly basis.
8. Maintains delegation/credentialing standards and business requirements (policy review) - NCQA, AAAHC. Researches and resolves delegated credentialing-related issues, including review of draft delegation addenda's from the Legal department to determine whether draft revisions may create compliance issues for AMERIGROUP. Provides recommendations to committee on process administration.
9. Maintains repository of delegated entities information, including audit results, narratives, credentialing committee notification, corrective action plan and any pertinent documents gathered in the ongoing monitoring process.
10. Coordinates with Health Plan and Provider Data Management regarding staff roster submission of new practitioners, changes to existing practitioners or provider terminations/dismissals.
11. Coordinates with Health Plan regarding termination process of any delegate who fails to maintain the delegation requirements set forth by AMERIGROUP to credentialing and recredentialing in compliance according to NCQA, AAAHC and CMS standards and regulatory requirements.
12. Leads biweekly Credentialing Department/Health Plan conference calls.
13. Reviews all licensing agency and Medicare/Medicaid sanction sites and communications on a monthly basis, reporting any findings to department management and Health Plan.
14. Supports the credentialing portion of annual state audits and ensures the submission of review materials as requested.
15. Reviews assigned Health Plan elements in Credentialing Manual and provides updates as appropriate regarding new or improved documentation resources and business rules.
16. Monitors progress of delegation activity to ensure timely submission and recommendation to Credentialing Committee and/or Vendor Selection Oversight Committee (VSOC) in a timely manner, to meet department Service Level Agreements and to maintain compliance requirements.
17. Generates basic and ad hoc reports of providers required for review by Medical Director and Credentialing Committee, for participation with AMERIGROUP.
18. Conducts credentialing training for new associates, and refresher training for existing associates. Provides input for training materials and job aids.
19. Maintains current knowledge of state guidelines and regulatory requirements, and all business rules pertaining to assigned Health Plan. Maintains current knowledge of the credentialing process and applicable database system (Amisys, Facets, and CACTUS) changes.
20. Maintains thorough knowledge of AMERIGROUP policies & procedures, NCQA, AAAHC, CMS and other related accreditation standards, state guidelines, regulatory requirements and any/all Health Plan specific requirements.
21. Assist in development of “best practice” department policies and procedures and workflows to create and maintain replicable processes within the department.
22. Assists with the applicant review and interview process.
23. Leads special projects.
24. Other duties as assigned.
EDUCATION AND EXPERIENCE:
Education Required:
• High School
Preferred:
• Bachelor's degree
Years and Type of Experience Required: Required:
• Minimum 4 years' experience using computer systems in an administrative setting
• Minimum 3 years' credentialing experience in another environment, or 2 years' progressive credentialing experience with AMERIGROUP
Preferred:
• Experience leading a team to meet quality and productivity goals.
Specific Technical Skills Required:
• Proficient in MS Office, including but not limited to Word, Excel
• Must be able to pass Credentialing Proficiency Test prior to expiration of initial 90 day period and on an annual basis.
• Must have strong analytical skills to analyze complex situations, ability to formulate decisions and execute a plan of action.
Preferred:
• Experience using Amisys, Cactus, MS Access, Facets
Certifications or Licensures Required:
• None
Preferred:
• CPCS – Certified Provider Credentialing Specialist or CMSC – Certified Medical Staff Coordinator
Other Required:
• Excellent verbal and written communication skills
• Strong attention to detail
• Strong organizational skills
• Appreciation of cultural diversity
• Maintains a positive demeanor, actively participate in team/department meetings and assist the department in identifying areas of opportunity while assisting in driving solutions
• Ability to interact with all levels of management
• Ability to set priorities and manage multiple demands effectively minimal direction and oversight.
SCOPE INFORMATION
# Direct Reports: 0
# Indirect Reports: Typically 3 or more
Budgetary $ Responsibility: N/A
PHYSICAL REQUIREMENTS:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Must be able to operate general office equipment including but not limited to: computer, phones and related media and information devices.
• Ability to communicate both in person and/or by telephone.
• Must be able to travel up to 60% of the time and adhere to AMERIGROUP travel policies and procedures
• Occasional lifting up to 25 lbs.
• Must be available for overtime as needed.
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
------------
Email to Friend Save Job Apply Now
------------
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