The Credentialing Specialist is Responsible for carrying out the day-to-day operations of the Credentialing Department, including performing activities related to the credentialing and re-credentialing of network providers, including those delegated, and facilities.

DUTIES/RESPONSIBILITIES:

• Initiates the collection of data for credentialing through automated credentialing systems and the Internet, as determined for Issues files.
• Maintains delegated provider process to ensure all files are complete, accurately entered into credentialing system.
• Obtain quarterly reporting and oversight reports. Analyzes Issue provider files for completeness, accuracy, consistency, gaps in time, lack of hospital admitting privileges, low insurance coverage, relevant references, etc.
• Identifies substantive issues and initiates further data collection as needed, from internal and external sources.
• Maintains thorough understanding/knowledge of the NCQA credentialing standards and how they relate to the credentialing/recredentialing processes defined by Point32Health, and maintains thorough understanding/knowledge of the Point32Health policies including rules, regulations, and legal issues relating to the credentialing/recredentialing processes. Understands end-to-end process flows in support of HCAS Collaborative.
• Familiar with all systems that support Credentialing processes.

In addition:

• Effectively interfaces with other Credential Specialists and Administrative Assistants, Provider Processing Center, Committee Reviewers, Provider Consultant Representatives, and/or other department personnel as necessary relating to credentialing/recredentialing.
• Coordinates the credentialing/recredentialing process and acts as liaison with hospitals and other health care entities with which we have delegated credentialing.
• Processes all Issue files, follows Non-Responder process according to all process steps and within required deadlines. Maintains production and quality performance standards.
• Occasionally may make site visits to entities for auditing purposes. Participates in status updates to departments, as necessary. Evaluates workflow for speed and efficiency.
• Evaluates quality improvement and makes suggestions to supervisor and team members for increasing effectiveness. Identifies potential problems and proposes solutions.
• Maintains credentialing records and related documents. May participate in training new staff in the credentialing processes and procedures. Oversee work and maintain orderly and systematic flow.
• Performs other duties as assigned with or without accommodation.

QUALIFICATIONS – what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE:

• Associates Degree or 2 -3 equivalent experience required. Certification by the National Association of Medical Staff Services is desirable
• Bachelor’s degree preferred.

EXPERIENCE (minimum years required):

• Minimum of 2 years experience working in health care

SKILL REQUIREMENTS:

• Working knowledge of Microsoft Word, Excel and Access database functions.
• Understanding of applicable systems in support of credentialing processes
• Ability to evaluate administrative policies and procedures.
• Ability to communicate effectively in both written and verbal forms.
• Ability to present professionally to other departments and provider.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be offered to work additional hours beyond standard work schedule.

ORGANIZATIONAL RELATIONSHIPS/SCOPE:

• Reports to the Manager or Supervisor, Credentialing

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

COVID Policy

Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R6240