Performs activities related to credentialing and re-credentialing of network providers, while ensuring adherence to the Health Plan, regulatory, industry and delegation standards. Conducts credentialing audits; oversees maintenance of documentation, provider files and related databases.
Responsibilities
Collaborates with supervisor to conduct the credentialing, re-credentialing and audit processes for all VNSNY CHOICE product lines. Serves as the day-to-day liaison between Credentials Verification Organization (“CVO”) and contracted entities with delegated credentialing and re-credentialing responsibilities.
Performs pre- and post-delegation audits of entities delegated for credentialing. Maintains documentation of these activities and reports findings to the management.
Prepares and executes correspondence to all providers concerning their credentialing approval or denial.
Maintains provider files. Ensures the confidentiality, integrity and security for all provider credentialing documentation for entry into VNSNY computer systems and hard copy files.
Coordinates processes related to provider denials, sanction activities and terminations to ensure applicable due process for appeals is followed.
Follows up with prospective providers regarding application status and contacts providers to secure missing documentation as applicable.
Interfaces with provider relations representatives regarding provider credentialing and re-credentialing status.
Updates credentialing and re-credentialing information in the provider databases.
Coordinates, prepares and presents provider file materials for Credentialing Committee meetings. Assists with preparation of agendas and minutes of Credentialing Committee meetings.
Trains colleagues on credentialing processes and procedures.
Produces various metrics related to the credentialing/re-credentialing functions for presentation to management, Credentialing Committee, and Delegation Oversight Committee.
Participates in special projects and performs other related duties as assigned.
Qualifications
Education:
Associate's degree in business, healthcare administration or a related field, or the equivalent required.Bachelor's degree in business, healthcare administration or a related field, or the equivalent preferred.Experience:
Minimum of two years managed care or hospital experience, preferably in the area of credentialing or provider relations required. Proven track record of credentialing and re-credentialing processes with an emphasis on compliance to NCQA, Medicare and Medicaid regulatory standards and requirements.Excellent organizational and PC skills required. Strong written and verbal communication skills, and ability to work independently in a team environment required.