What are the responsibilities and job description for the CREDENTIALING SPECIALIST position at Somos Your Health, LLC?
Job Description: Role and Responsibilities
Experienced credentialing specialist with the willingness to learn quickly in an adaptable start-up healthcare environment. Solid knowledge of Managed Care as well as credentialing standards. Ability to communicate inter-departmentally, as well as cross-departmentally on a daily/weekly basis.
Performs and coordinates credentialing delegation functions for contracted MCOs to maintain a quality provider network.
Serves as a liaison to the IPA to ensure current and adequate credentialing processes are in place.
Leads quarterly Credentialing Committee Meetings
Facilitates communication between Legacy IPA’s, TPA, and Health Plans
Monitors timelines of health plans
Interacts with health plan representative regarding enrollment audits; problems and claims resolutions; addressing potential corrective action plans and monitoring for successful resolution
Ensures all department policies and procedures are reviewed annually, updated as necessary, and remain in accordance with the State, CMS, or other regulatory requirements where applicable
Highly focused on the review of credentialing files and reporting to work with candidates and cross-functional teams to obtain missing, incomplete, and expiring items
COMPETENCIES AND QUALIFICATIONS
Associate’s or bachelor’s degree preferred
Minimum two years of experience managing credentialing, privileging, or similar healthcare professional verification and the organization's accreditation processes are required.
Minimum 1 year of experience in health plan enrollments and management is required
Familiar with NCQA Credentialing and re-credentialing standards
POSITION TPE AND EXPECTED HOURS OF WORK
Primary Location: 2910 Exterior Street, 1st Floor Bronx, NY 10463
Hours Per Week: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours: 40 hours per week
Job Schedule: Full-time - schedule to be determined by manager
Job Type: Standard
Employee Status: Regular
Employee Group/Union Affiliation: Salaried, Non-Union, Exempt
Job Level: Manager with Direct Reports
Job Category: External Affairs / Relations
Department: MSO Operations and Solutions
Travel: Yes, 5 % of the Time About SOMOS Innovation, LLC:
Employees and Board Members of SOMOS Innovation, LLC only access PHI/EPHI on a need-to-know basis. Employees and Board members may only access confidential information that is authorized within their scope of duties and responsibilities and is responsible for the safeguarding of this information. SOMOS may periodically review, revise and/or revoke an employee’s or Board member’s privileges to access confidential (PHI) information.
Please note this job description is not designed to cover or contain all activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Experienced credentialing specialist with the willingness to learn quickly in an adaptable start-up healthcare environment. Solid knowledge of Managed Care as well as credentialing standards. Ability to communicate inter-departmentally, as well as cross-departmentally on a daily/weekly basis.
Performs and coordinates credentialing delegation functions for contracted MCOs to maintain a quality provider network.
Serves as a liaison to the IPA to ensure current and adequate credentialing processes are in place.
Leads quarterly Credentialing Committee Meetings
Facilitates communication between Legacy IPA’s, TPA, and Health Plans
Monitors timelines of health plans
Interacts with health plan representative regarding enrollment audits; problems and claims resolutions; addressing potential corrective action plans and monitoring for successful resolution
Ensures all department policies and procedures are reviewed annually, updated as necessary, and remain in accordance with the State, CMS, or other regulatory requirements where applicable
Highly focused on the review of credentialing files and reporting to work with candidates and cross-functional teams to obtain missing, incomplete, and expiring items
COMPETENCIES AND QUALIFICATIONS
Associate’s or bachelor’s degree preferred
Minimum two years of experience managing credentialing, privileging, or similar healthcare professional verification and the organization's accreditation processes are required.
Minimum 1 year of experience in health plan enrollments and management is required
Familiar with NCQA Credentialing and re-credentialing standards
POSITION TPE AND EXPECTED HOURS OF WORK
Primary Location: 2910 Exterior Street, 1st Floor Bronx, NY 10463
Hours Per Week: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours: 40 hours per week
Job Schedule: Full-time - schedule to be determined by manager
Job Type: Standard
Employee Status: Regular
Employee Group/Union Affiliation: Salaried, Non-Union, Exempt
Job Level: Manager with Direct Reports
Job Category: External Affairs / Relations
Department: MSO Operations and Solutions
Travel: Yes, 5 % of the Time About SOMOS Innovation, LLC:
Employees and Board Members of SOMOS Innovation, LLC only access PHI/EPHI on a need-to-know basis. Employees and Board members may only access confidential information that is authorized within their scope of duties and responsibilities and is responsible for the safeguarding of this information. SOMOS may periodically review, revise and/or revoke an employee’s or Board member’s privileges to access confidential (PHI) information.
Please note this job description is not designed to cover or contain all activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
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