CLAIMS AND CREDENTIALING ANALYST

Job Purpose

The Claims and Credentialing Analyst will be a pivotal role in analyzing and coordinating all activities of the Provider Data team by evaluating and refining processes, conducting comprehensive data analysis, and ensuring compliance with all applicable State, CMS, contractual guidelines and ensuring provider compliance with credentialing standards.

Job Responsibilities

• Coordinate provider credentialing process to increase efficiency and ensure that credentialing deadlines are met.
• Research and solve credentialing/re-credentialing delays & issues with enrollment in a timely manner.
• Manage confidential information of internal staff (Physicians, Nurse Practitioners).
• Ensure demographic updates are reviewed and verified for processing.
• Ensure the database is kept accurate and updated.
• Maintain necessary logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing to ensure requirements are met in a timely manner.
• Prepare documents for Credentialing Committee review.
• Outreach to provider for information verification and miscellaneous inquiries, i.e. provider portal access, nursing home documentation, medical records retrieval, etc.
• Perform in-depth provider claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency.
• Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements.
• Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments.
• Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.
• Review monthly capitation payments in accordance with contractual obligations.
• Perform analysis on capitation payments to determine trends or discrepancies on the payments as well as determine improvements on the process.
• Prepare analysis on network provider performance through the development of monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirement and identify areas for improvement.
• Provide productivity and issues reports for Management.
• Remain current on policies affecting provider credentials and enrollment processes.
• Other duties as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

Qualifications

Education: Bachelor’s Degree, and/or equivalent work experience.

Experience

• A minimum of three (3 ) years of credentialing experience.
• Preferred: Credentialing in a Healthplan setting.
• Microsoft Office/Suite Proficient (Excel, Outlook, Word, etc.)
• Highly Organized.
• Able to multitask efficiently and effectively.
• Solid problem solving and time management skills.
• Have the ability to review and draft correspondence in email and word processing systems.
• Professional, Friendly, and Skillful Communication Skill Set.

License: None Required, Certified Provider Credentialing Specialist – Preferred.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
• Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max)

$75,000.00 - $85,000.00