Lead - Credentialing Operations Specialist

Avera•Sioux Falls, SD

16d•$24 - $32

About The Position

The Lead – Credentialing Operations Specialist plays an integral role on the Avera Health Plan team by supporting the operations and management of Avera Health Plans Provider Credentialing. This role serves as the subject matter expert related to Avera Health Plans provider credentialing for internal and external clients and functions as a resource for credentialing coordinators, Avera Health Plans personnel, vendors and providers.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Bachelor's Healthcare Administration, Business, Health Information or a related field or equivalent years of related experience.
Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) or Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)
4-6 years Experience in credentialing within a hospital, insurance or managed care environment.
In-depth knowledge of provider credentialing processes, regulatory requirements, and industry best practices.

Nice To Haves

Strong analytical abilities with proficiency in data analysis and KPIs (Key Performance Indicators) development.
Proven ability to enhance operational efficiency in fast-paced settings.
Ability to drive continuous process improvements in a fast-paced environment.
Experience with the following software: Outlook, Microsoft, Excel, CACTUS/Provider, Epic/Tapestry, Health Trio and Maccess.

Responsibilities

Oversees daily credentialing operations, ensuring compliance, quality, and timely turnaround of credentialing activities.
Monitors quality of work by conducting regular audits and tracking results.
Resource for provider credentialing coordinators on department procedures using advanced knowledge of credentialing, NCQA requirements, State and Federal Credentialing laws and system configuration within the credentialing software system.
Provides guidance, resolves interdepartmental issues, and serves as credentialing subject matter expert for internal and external departments.
Monitor shared inboxes and respond within required timeframes.
Support departmental projects and accreditation activities, including NCQA audits.
Develops and maintains standard operating procedures, job aids and training materials for internal staff and providers completing credentialing.
Review credentialing files and prepare Level 2 credentialing files for Credentialing Committee meetings.
Prepares credentialing packets and works with physician Medical Directors for review.
Ensures decision process is completed within set time-frames.
Monitors monthly metrics and aging reports, meeting with other departments to make to make necessary improvements when key performance indicators are not meeting goals.