Resp & Qualifications

PURPOSE:
Provides analysis and reporting to enable the effective credentialing of institutional and ancillary providers by obtaining provider related data; analyzing gaps in provider records; designing solutions; carrying out necessary credentialing activities. This role using expertise in credentialing operations, analysis and reporting skills sets to credential institutional and ancillary providers for network participation with CareFirst BlueCross BlueShield and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.

Note: We are looking for an experienced professional in the greater Baltimore/Washington metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

Research and improve institutional and ancillary provider information by examining and researching provider data gaps by obtaining facts, analyzing problems/identifying root cause recommending and facilitating resolution. Ensures compliance of institutional provider records through continuous review and analysis, updating and maintaining of current required primary source verification documentation, and ongoing communication with institutional providers to obtain reverification documentation. Maintains the provider file, the Provider Information Control (PICS) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, re-credentialing, demographic updates, terminations, and all other provider file maintenance activities.
Supports networks operations systems by providing operating information to providers and internal stakeholders; answering questions; providing education and training to others as needed. Ensures accurate and timely day to day processing of new institutional providers in accordance with regulatory requirements and timeframes, improves provider experience, and supports Provider Information & Credentialing department on inventory control.
Contributes to operations analysis and organization success by welcoming related, different, and new requests; helping others accomplish job results, development of Standard Operating Procedures (SOP) and other essential documentation. Produces weekly inventory reporting, identifying trends and issues, developing recommendations to improve processes.
Verifies network operations systems by developing testing methods, conducting and documenting tests. Ensures audit readiness and timely completion of required audit reporting.
Improves operations analysis job knowledge by attending training sessions, reading technical publications. Supports department, peers, and leadership to ensure regulatory and timeliness goals are met.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Business Administration 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: 2 years experience in (level 2 or above) operational role.

Knowledge, Skills and Abilities (KSAs)

Ability to recognize, analyze, and solve a variety of problems.
Highly proficient in Microsoft Office and similar applications.
Organized, detail-oriented while meeting strict deadlines.
Excellent communication skills both written and verbal.
Demonstrate ability to work independently.
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: $44,568 - $88,517
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

Credentialing Center
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
#LI-NH2