Credentialing Representative (44299)

This position is responsible for processing provider application for network entry and reappointment, including primary source verification of providers credentials according to Plans policy, NCQA standards and regulatory requirements, conduct site visits at provider offices for credentialing and re-credentialing, and maintain providers credentialing records between credentialing cycles.

Responsibilities include, but are not limited to the following:

• Intake of requests for credentialing and re-credentialing and ensure that all applicable documents have been received and initiate outreach to the provider for missing documentation
• Perform primary source verification of provider applications submitted for process for initial credentialing and re-credentialing according to regulatory requirements and company standards
• Provide status updates to providers on the progress of their initial credentialing and re-credentialing application
• Effective data entry of documentation from initial and re-credentialing applications in CACTUS and ensure accuracy of data entered for all providers
• Conducts self-reviews of initial and re-credentialing applications prior to submitting to credentialing committee to ensure standards are applied
• Manages and prioritizes assigned work to ensure compliance with regulatory requirements and departments goals are met compliance
• Conduct monthly checks of, or more often as appropriate, disciplinary action reports issued by State licensure bodies; Medicaid and Medicare exclusion and take appropriate action as defined in policy
• Conduct quality onsite assessment at provider offices as assigned
• Assist in audits of the Plan by regulatory agencies
• Assist in the oversight of delegated credentialing activities
• Initiate requests for updates to provider records in claims system when data discrepancies are identified during re-credentialing process
• Serve as team representative at internal meetings
• Maintenance of providers credentialing records between credentialing cycles
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents