Resp & Qualifications
PURPOSE:
The Credentialing Program Specialist is responsible for monitoring, oversight, and reporting to ensure Credentialing Program compliance and completion of an array of tasks to support compliance with all NCQA Credentialing standards and regulatory timeframes for credentialing and re-credentialing transactions. The incumbent may be involved in collaboration and coordination of deliverables with Medical Directors, the Credentialing Advisory Committee (CAC), and the Quality Improvement Council.
ESSENTIAL FUNCTIONS:
- Prepare cases requiring Medical Director, Pre-CAC, and CAC review with summary and appropriate documentation, and communication of decisions; review and resolution of escalated matters from Credentialing analysts to ensure continued processing within timeliness goals. Prepare lists of credentialed and recredentialed practitioners for Medical Director review and approval and complete pre and post approval tasks. Establish and maintain reporting to Quality Improvement Council and Accreditation team demonstrating compliance with NCQA Credentialing Standards including mock audits, annual update of policies and procedures; Credentialing System Controls Monthly Monitoring Reports; evidence of Ongoing Monitoring (sanctions, adverse event log, quality of care complaints log; etc.); organizational provider reporting; and delegation oversight reporting. Ensure recredentialing compliance for professional and institutional providers.
- Ensure compliance with NCQA Credentialing standards and delegated agreements by Delegates and CareFirst through reporting and oversight of semi-annual reporting, annual delegate audits, communication with delegates, and reporting to Quality Improvement Council.
- Comply with audit and regulatory inquiries for contracts and credentialing document requests from internal and external sources within required timeframes.
- Maintain knowledge of healthcare practices, regulatory and accreditation requirements related to credentialing to provide credentialing support as a subject matter expert to the credentialing staff and management in participation/contracting decision making. Periodically review and revise medical review policies and procedures to ensure effectiveness.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Business or Healthcare related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 5 years' experience in credentialing and re-credentialing.
Knowledge, Skills and Abilities (KSAs)
- Knowledge and understanding of medical terminology to address codes and procedures.
- Excellent communication skills both written and verbal.
- Proficient in Microsoft Office programs.
- Ability to interpret federal/state regulatory requirements.
- Strong analytical and project management skills and overall business acumen.
- Strong verbal and written communication skills; ability to write reports for various audiences.
- Ability to positively interface with internal and external customers.
- Ability to effectively develop and implement effective improvement strategies in a fast-paced environment.
- Ability to effectively handle difficult, irate and/or emotional external customers (providers and members),
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $50,544 - $100,386
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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