Provider Credentialing Analyst

  • Location
    Columbia, Maryland
  • Job type
    Contract/Temporary
  • Category
    Call Center & Customer Service - Customer Service

A large healthcare company in the Mid Atlantic has an immediate need for a Provider Credentialing Analyst!

The associate analyzes and researches applications and correspondence from professional providers and ancillary providers for participation or non-participation in the the company's networks. Maintains and updates all aspects of the corporate databases for network providers, including credentials, addresses, contracting status, etc. so that the data can be used throughout the organization. Process all termination and cancellation requests from professional providers. Service external and internal inquiries regarding provider status and credentialing criteria. Performs primary source verification on new practitioners and performs re-credentialing of existing practitioners every 3 years in accordance with NCQA guidelines. Processes applications received via paper applications and via CAQH.

PRINICIPAL ACCOUNTABILITIES:

35% Analyzes and researches credentialing applications/provider contracts to verify that appropriate information has been obtained as well as handles incoming and outgoing correspondence regarding the applications. Determines the appropriate networks for participation and obtains the appropriate executed contracts. Maintains the on-line provider file and hardcopy file with updated provider information- Credentials and re-credentials providers to appropriate levels. Maintains the Application Log in accordance with state legislation.


30% Assign provider numbers and updates demographic information on the corporate database for publishing provider information in our various directories. Processes applications and updates in accordance with applicable state laws and guidelines. Maintains database for all provider information updates to support corporate mainframe system for all network provider or subscriber inquiries and is fundamental in supporting the provider special pricing process.

20% The incumbent addresses questions involving professional entities and
Contractual questions. Determines the nature of inquiry, researches available information and determines the proper actions required. Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status and provider file updates.

10% Prepares written responses in order to obtain incomplete or missing information. Mails appropriate provider packet when required. Mails confirmation letter to professional providers identifying necessary provider numbers for proper billing.


5% Verification and release of all data entered into the database. Complete updates to the departments inventory control system (IACS) documenting cases completed or case in a pend status.


SCOPE DATA:

Accountable for the maintenance of the on-line and hardcopy files of over 35,000 providers participating in the company's networks, including credentials, contracting status and practice information. Failure to efficiently process provider information/applications update and maintain the files would result in inaccurate benefits applications for members, incorrect payment to providers, inaccurate data regarding provider networks, inaccurate provider directories and non-compliance with NCQA, federal and state regulations.

QUALIFICATION REQUIREMENTS:

Credentialing or Provider file maintenance experience
Analytical Skills to research and analyze data
High school diploma with 2 years of college or commensurate work experience.
3-5 years direct experience with provider contracting, credentialing or network management.
Knowledge of medical terminology
Strong service skills and possess ability to remain calm in stressful situations with medical professionals.


PHYSICAL DEMANDS:

The physical demands described here a representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.

The associated is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.


Equal Opportunity Employer
Minorities/Women/Veterans/Disabled

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Reference number US_EN_1_027071_11896034