Credentialing Analyst - Hybrid/Remote (Candidates must reside in the state of South Carolina)

Job Summary

Administer all functions related to the enrollment and re-credentialing of providers and groups with governmental and commercial payers.

Minimum Qualifications

Minimum Education: High School Diploma or Equivalent
Minimum Years of Experience: 3 Years of managed care experience in positions that involved or provided exposure to the credentialing process.
Substitutable Education & Experience: 3 Years of experience can be substituted for one of the following:
Bachelor's Degree;
Associates Degree with 1 year of managed care experience in positions that involved or provided exposure to the credentialing process.
Required Certifications/Licensure: None.
Required Training: Experience in database, spreadsheet and word processing applications;
Experience with problem solving techniques;
Basic understanding of revenue cycle;
Working knowledge of managed care terminology and reimbursement methodologies;
Working knowledge of NCQA credentialing criteria.

Essential Functions

• Develops and implements systems and procedures to ensure all credentialing processes are completed in accordance to relevant regulation, policies and standards.
• Investigates, analyzes and/or corrects any third payer issues including and not limited to appropriate  provider and/or group set-up errors.
• Develop, analyze and trend reports as related to Credentialing processes. 
• Facilitates and coordinates third party payer audits for delegated credentialing.
• Work with Accounting to ensure EFT applications are completed where applicable to provider/group enrollment.
• Knowledgeable of credentialing trends across industry through publications, attending state seminars, educational workshops and conferences.
• Initiates and coordinates the acquisition and receipt of all credentialing documents from new and existing providers and groups.
• Utilizes all available resources (on-line websites, software) to aid in the background checks and license verifications of all provider applications.

Duties & Responsibilities

• Coordinates the processing, distribution and management of all credentialing and accreditation documents for affected providers to applicable health plans.
• Communicates with all applicable internal areas on status and completion of credentialing with applicable payers.
• Maintains a comprehensive credentialing database, ensuring data integrity of provider information.
• Administers and coordinates provider licensing, ensuring receipt within regulation parameters and payer requirements.
• Develops and maintains strong relationship with team members and outside agencies to ensure harmonious relationships.
• Communicates requested information to payers in a timely and professional manner.
• Maintains and ensures strict confidentiality of files and databases.
• Performs all other duties as assigned.