Credentialing Associate

Overview

Performs activities related to credentialing and re-credentialing of network providers, while ensuring adherence to the Health Plan, regulatory, industry and delegation standards. Conducts credentialing audits; oversees maintenance of documentation, provider files and related databases. Works under general supervision.

Compensation Range:$25.46 - $31.86 Hourly

What We Provide

• Referral bonus opportunities

• Generous paid time off (PTO), starting at 20 days of paid time off and 9 company holidays  

• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability   

• Employer-matched retirement saving funds  

• Personal and financial wellness programs   

• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care    

• Generous tuition reimbursement for qualifying degrees  

• Opportunities for professional growth and career advancement   

• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities    

• Interdisciplinary network of colleagues through the VNS Health Social Services Community of Professionals.

What You Will Do

• Collaborates with supervisor to conduct the credentialing, re-credentialing and audit processes for all VNS Health Plans product lines. Serves as the day-to-day liaison between Credentials Verification Organization (“CVO”) and contracted entities with delegated credentialing and re-credentialing responsibilities.

• Performs pre- and post-delegation audits of entities delegated for credentialing. Maintains documentation of these activities and reports findings to the management.

• Prepares and executes correspondence to all providers concerning their credentialing approval or denial.

• Maintains provider files. Ensures the confidentiality, integrity and security for all provider credentialing documentation for entry into VNS Health computer systems and hard copy files.

• Coordinates processes related to provider denials, sanction activities and terminations to ensure applicable due process for appeals is followed.

• Follows up with prospective providers regarding application status and contacts providers to secure missing documentation as applicable.

• Interfaces with provider relations representatives regarding provider credentialing and re-credentialing status.

• Updates credentialing and re-credentialing information in the provider databases.

• Coordinates, prepares and presents provider file materials for Credentialing Committee meetings. Assists with preparation of agendas and minutes of Credentialing Committee meetings.

• Trains colleagues on credentialing processes and procedures.

• Produces various metrics related to the credentialing/re-credentialing functions for presentation to management, Credentialing Committee, and Delegation Oversight Committee.

• Participates in special projects and performs other duties as assigned.

Qualifications

Education:

• Associate's Degree in business, healthcare administration or a related field, or the equivalent required

• Bachelor's Degree in business, healthcare administration or a related field, or the equivalent preferred

Work Experience:

• Minimum of two years managed care or hospital experience, preferably in the area of credentialing or provider relations required

• Proven track record of credentialing and re-credentialing processes with an emphasis on compliance to NCQA, Medicare and Medicaid regulatory standards and requirements.

• Excellent organizational and PC skills required

• Strong written and verbal communication skills, and ability to work independently in a team environment required