Health Choice is dedicated to improving the health and well-being of the people and communities we serve.
Health Choice believes in a personal approach to health care right in your community. We built our health care plan around you. Our goal is to give you quality health care, programs, and services to support you on your path to wellness.
Health Choice provides exceptional customer service and culturally competent care through:
- Compassionate and responsive member services team
- Collaboration with community physicians to help members get the health care they need.
- Providing culturally competent health care, including extensive translation and interpretation services
- Health programs to help members and their families stay healthy
Position Purpose: Reporting to the Credentialing Manager, the Credentialing Coordinator facilitates the accurate and efficient Credentialing and Recredentialing of SHCN and SMG providers in alignment with State, Federal, and NCQA standards.
- Responsible for ensuring timely processing credentialing, recredentialing, practitioner files, organizational files and the credentialing database, and coordination of the Credentialing Committee meeting including meeting minutes.
- Conduct internal and external validation of credentialing file audits, and address identified issues in a timely manner.
- Facilitate prompt coordination with the Credentialing Verification Organization (CVO) and monitor files in-process, promptly addressing incoming files for processing.
- Review and maintain all applications for accuracy and completeness, ensure primary source verification, and overall processing time frames are met.
- Generate forms, letters, checklists, and maintain the internal tracking data base/data entry, ensuring complete and accurate data entry.
- Contribute toward the coordination of the Credentialing Committee by accurate and complete preparation of credentialing and recredentialing files. Identify and communicate agenda items to the Credentialing Manager to be addressed at the Credentialing Committee.
- Facilitate preparation of files for electronic storage.
- Participate and preparation of Delegated Credentialing audits, ensuring compliance with Federal, Multi-State, Multi-Payor, and NCQA requirements.
- Coordinate with Network Development, Provider Onboarding, or other sources as necessary on follow-up items needed to complete the credentialing process. Communicate to internal and external departments regarding status of provider and organizational credentialing.
- Maintain on-going participation in cross-training activities. Actively engage in addressing special projects as they arise, conducting preliminary research and follow-up, and tracking/monitoring to facilitate on-going reporting of project status.
- Provide recommendations and feedback regarding development of process improvements and/or standardization practices.
- Other duties as assigned.
Education / Experience / Other Requirements
- Associates degree in a related field (or equivalent combination of education and experience).
- NAMSS CPCS Certification Preferred.
Years of Experience:
- A minimum of three years of relevant experience in healthcare related environment, preferably within a credentialing/recredentialing environment and knowledge national accreditation or regulatory criteria.
- Multi-State and multi-payor related Credentialing knowledge and experienced strongly preferred, required within the first year.
- Microsoft Office software (Word, Access, Excel, PowerPoint), and preferably experience with Credentialing systems.
- Previous Managed Care and/or Medicaid experience strongly preferred.
- Ability to analyze and evaluate data and other provider related problems in order to develop alternative solutions for a positive outcome.
- Ability to multi-task and prioritize workload, manage multiple priorities, and pay meticulous attention to detail.
- Thorough understanding of managed care principles and physician practice operations, with an understanding of health plan provider enrollment and credentialing preferred.
- Excellent organizational skills, proven project management expertise; Strong verbal and written communication skills.
- Outstanding interpersonal skills, able to quickly establish a trusting rapport with individuals at all levels.
- Requisite poise, judgment, and trustworthiness to represent SHCN to internal and external groups.
- Maintains information in a confidential manner according to policy.