Senior Credentialing Representative - Quality Auditor

About the position The Senior Credentialing Representative is responsible for ensuring that credentialing information and data meets internal and external quality standards and requirements. Internal audits are performed against established standards for all credentialing and recredentialing functions within the Credentialing Center of Excellence (CCoE). The SCRA will document findings, identify trends, and recommend opportunities for improvement.

Responsibilities

• Performs daily audits of credentialing and recredentialing files utilizing standardized audit template
• Ensures audits are performed within established timeframes
• Communicates identified errors to credentialing representatives and specialists utilizing established processes
• Participates in audit result review and track and trend of results
• Participates in root cause analysis
• Reviews repeat errors for potential training opportunities
• Provides explanations and interpretations within area of expertise
• Identifies potential process improvement needs to workflows and procedures
• Communicates potential and identified trends to leadership
• Collect and review credentialing files and materials for submission to delegating health plans at time of initial and annual delegation oversight audits
• Collect and review submitted sub-delegated files and materials at time of pre-assessment and annual delegation oversight audits
• Other department duties as assigned

Requirements

• Demonstrated understanding credentialing information processes
• Established knowledge of credentialing requirements to include NCQA, CMS, and state-specific regulations
• Attention to detail, ability to identify inconsistencies and missing information
• Consistently delivers excellent quality of credentialing files processed
• Analytical and critical thinking skills
• Ability to research and evaluate credentialing criteria when questions or discrepancies are presented
• Strong communication skills, ability to communicate clearly and professionally in written or oral formats
• Ability to identify problems, analyze data and recommend solutions
• Ability to maintain confidential information in accordance with Company policies, state, and federal regulations
• Ability to manage detail and work with accuracy
• Ability to acquire knowledge of technical resources within the organization
• Ability to work independently
• Ability to establish and maintain cooperative working relationships with individuals at all levels including teammates from other teams
• Ability to work with frequent interruptions
• Ability to prioritize work and skill in working effectively under deadlines and changing priorities
• Demonstrated knowledge of Microsoft Office applications such as Word, Excel, and Outlook
• Intermediate level skills working in Microsoft Excel
• Consistently delivers excellent quality of work
• High School Diploma/GED (or higher)
• 2+ years of experience in credentialing
• 1+ years of proven consistent quality audit scores passing or exceeding requirements
• 1+ years of experience using credentialing software or software managing provider information

Nice-to-haves

• Experience using MD-Staff credentialing software

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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