Gold Kidney Health Plan
Gold Kidney Core Values:
Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No-Limits Mindset and Results Oriented.
Purpose and Scope:
The Credentialing Analyst is responsible for efficient credentialing operations, coaching and training of Department staff. He/she will coordinate and will be accountable for the daily activities of business support, technical or production teams or unit. He/she will act as the primary point person for the Credentialing team by organizing the team workflow, providing direction, assistance to the credentialing staff, and organizing the activities of the Credentials Committee. They will be responsible for all activities associated with credentialing or re-credentialing physicians and providers. Duties will include processing provider CAQH (Council for Affordable Quality Healthcare) applications and re-applications ensuring high quality standards are maintained. Conducts audits and provides feedback to reduce errors and improve processes and performance. Additionally, this position will be responsible for the development of credentialing policies and procedures and may oversee primary source verification activities
Principal Duties and Responsibilities:
- Assumes the lead role in the development, maintenance, and monitoring of an efficient and streamlined credentialing process that identifies and accurately tracks providers’ credentialing status.
- Will be the lead role in the monitoring of the credentialing database for day-to-day operations.
- Communicates with providers both verbally and in writing regarding verification of credentialing information.
- Ensures accuracy of staff data entry of credentialing data into credentialing software vendor(s) database.
- Owns output at task level.
- Sets priorities for the team to ensure task completion.
- Coordinates work activities with others
- Develops and implements a strategy to meet short-term objectives.
- Identifies and resolves operational problems using defined processes, expertise, and judgment.
- Decisions guided by policies, procedures, and business plan.
- Product, service, or process decisions are most likely to impact individual employees and/or customers (internal or external)
- Ensures that all credentialing activities are performed in conformance with state credentialing policies and procedures, NCQA (National Committee on Quality Assurance) accreditation standards, and state and federal credentialing requirements.
- Organizes and coordinates Credentialing Committee meetings Presents records for credentialing approval at Credentials Committee meetings.
- Ensure staff are accurate and timely credentialing and re-credentialing providers.
- Participates in internal audits of delegated credentialing entities as needed; tracks and ensures the timely completion of these activities and assures that complete documentation is included in the provider credentialing files.
- Provides direction and training to credentialing staff to resolve complex credentialing issues.
You will be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Physical Demands and Working Conditions:
- Ability to view the computer screen for extended periods of time.
- Exerting up to 20 pounds of force occasionally and/or a negligible amount of
force frequently or constantly to lift, carry, push, pull, or otherwise move
objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
No supervision required.
- High School Diploma or GED is required
- Undergraduate Degree and/or equivalent experience is preferred
Experience and Required Skills:
- 3+ years of healthcare provider experience.
- 1+ years of recent credentialing experience in a managed care organization, working with compliance workflows and processes, including NCQA policies and practices.
- 1+ years of experience in researching and applying government regulatory information.
- Ability to work an 8-hour shift between 8:00am – 5:00 pm local time.
- Proven written and oral communication skills.
- Demonstrated team building skills.
- Excellent verbal, analytical, organizational, and written skills.
- Ability to motivate teams and effectively manage personnel.
- Intermediate level of proficiency with MS Excel and Word.
I will review and comply with the Code of Business Conduct and all relevant Company and Division policies and procedures, and local, state, and Federal laws and regulations. I acknowledge that I have read and accepted this job description. I understand what is expected of me in this position, and I am able to perform the essential functions as outlined with or without reasonable accommodation. Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate supervisor or my Human Resources representative.
|Job Category||Business Development|