Credentialing Operations Specialist
Job Location:
Sioux Falls, SD - USA
Monthly Salary:
Posted on:
Vacancies:
Job Summary
Location:
Worker Type:
RegularWork Shift:
Primarily days with possible weekends/evenings/holidays (United States of America)Pay Range:
The pay range for this position is listed below. Actual pay rate dependent upon experience.
$22.00 - $29.50Position Highlights
This is a brand-new role! Avera Health Plans is expanding our credentialing services.
You Belong at Avera
Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.
A Brief Overview
The Credentialing Operations Specialist is responsible for coordinating provider credentialing and enrollment activities in compliance with NCQA state and federal requirements. Reviews applications for accuracy and completeness partners with providers and internal teams to resolve issues and prepares files for Medical Director and committee review. Maintains credentialing data supports audits and ensures timely compliant communication regarding provider status.
What you will do
- Knowledge of NCQA Credentialing standards and all applicable state and government laws regarding credentialing and applies them to the credentialing process.
- Coordinates the initial enrollment and re-enrollment process for providers and facilities contracted with Avera Health Plans.
- Reviews initial and reappointment credentialing applications to ensure compliance with NCQA process. Ensures application completeness and works with providers to gather missing or incomplete information.
- Reviews credentialing applications returned from the Central Verification Organization (CVO) to ensure Primary Source Verifications (PSV) were done accurately and timely consistent with NCQA state and federal credentialing requirements. Accurately determines and documents clean vs red flag files.
- Coordinates with Medical Director for file review of clean and red flag files. Gathers additional information based on the Medical Directors feedback.
- Assists in monthly Credentialing Committee File preparation.
- Generates and sends out compliant communication to providers related to credentialing terminations denials and approvals consistent with Avera Health Plans policies and NCQA requirements.
- Performs accurate data entry and maintains enrollment records within the credentialing system and internal databases.
- Responds to applicants and current providers regarding the credentialing process and status.
- Serves as a resource to internal and external clients by answering credentialing questions conducting audits and doing file preparation for audits.
Essential Qualifications
The individual must be able to work the hours specified. To perform this job successfully an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others hear understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge skills and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions as long as the accommodations do not cause undue hardship to the employer.
Required Education License/Certification or Work Experience:
- Associates Two-year college or technical school or an equivalent combination of education and experience.
- 1-3 years Credentialing experience provider enrollment provider contracting compliance advanced medical or administrative experience and/or training.
Preferred Education License/Certification or Work Experience:
- Bachelors In a related field of health information/healthcare or business.
- Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) or
- Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)
Expectations and Standards
- Commitment to the daily application of Averas mission vision core values and social principles to serve patients their families and our community.
- Promote Averas values of compassion hospitality and stewardship.
- Uphold Averas standards of Communication Attitude Responsiveness and Engagement (CARE) with enthusiasm and sincerity.
- Maintain confidentiality.
- Work effectively in a team environment coordinating work flow with other team members and ensuring a productive and efficient environment.
- Comply with safety principles laws regulations and standards associated with but not limited to CMS The Joint Commission DHHS and OSHA if applicable.
Benefits You Need & Then Some
Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced healthy lives. Benefits are designed to meet needs of today and into the future.
PTO available day 1 for eligible hires.
Up to 5% employer matching contribution for retirement
Career development guided by hands-on training and mentorship
Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability Veteran Status or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application please call 1- or send an email to .
Required Experience:
IC
About Company
Move your health forward with Avera. Learn about our integrated health system of hospitals, clinics, doctors and community support in South Dakota, Minnesota, Iowa, Nebraska and North Dakota.
