A Bachelor's degree or equivalent work experience.
At least three years of credentialing experience.
Proficiency with Microsoft Office, including Excel, Outlook, and Word.
Ability to review and draft correspondence using email and word-processing systems.
Ability to stand for up to six hours per day and sit in a sedentary position for up to six to eight consecutive hours.
Ability to lift, push, or pull up to 50 pounds in accordance with applicable OSHA guidelines.
Ability to bend or squat safely to perform essential job functions.
Ability to safely use stairs, climb, and walk to access work areas.
Agility and fine motor skills to operate equipment, devices, instruments, and tools, including typing.
Visual ability to read documentation and type or write accurately.
Ability to listen attentively, document information accurately, and speak clearly with patients, community members, coworkers, clients, and providers.
Cognitive ability to make decisions, reason, process information, and perform analysis.
Responsibilities
Coordinate the provider credentialing process to improve efficiency and meet credentialing deadlines.
Research and resolve credentialing and re-credentialing delays and enrollment issues in a timely manner.
Manage confidential information concerning internal staff, including physicians and nurse practitioners.
Ensure demographic updates are reviewed and verified for processing.
Maintain an accurate and current database.
Maintain logs, lists, records, and current documentation required for physician and provider credentialing and re-credentialing, ensuring requirements are met on time.
Prepare documents for Credentialing Committee review.
Contact providers to verify information and address inquiries, including portal access, nursing home documentation, and medical-record retrieval.
Conduct in-depth provider claims analysis using multiple datasets, perform 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 regulatory compliance.
Coordinate with the Finance Department on check runs and provider payments, including refunds, overpayments, and underpayments.
Review and investigate claims for adjudication by the Third-Party Administrator, applying contractual provisions in accordance with provider contracts and authorizations.
Review monthly capitation payments for compliance with contractual obligations.
Analyze capitation payments to identify trends or discrepancies and determine process improvements.
Analyze network provider performance by developing monthly provider scorecards and collaborating with stakeholders to assess contractual compliance and identify areas for improvement.
Provide productivity and issue reports to management.
Stay current on policies affecting provider credentials and enrollment processes.
Perform other duties as assigned.
Desired Qualifications
Credentialing experience in a health plan setting.
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.
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
Every application is reviewed by our recruitment team. We do not use AI to make hiring decisions or automatically reject applicants. All employment decisions are based on job-related qualifications and applicable employment laws.