CLAIMS AND CREDENTIALING ANALYST

Job Responsibilities

• Cook up the credentialing process to boost efficiency and guarantee credentialing deadlines are met.
• Research and resolve credentialing/re-credentialing delays & issues with enrollment in a timely manner.
• Manage confidential information of internal staff (Physicians, Nurse Practitioners).
• Ensure demographic updates are reviewed and verified for processing.
• Maintain necessary logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing to ensure requirements are met in a timely manner.
• Prepare documents for Credentialing Committee review.
• Outreach to provider for information verification and miscellaneous inquiries, i.e. provider portal access, nursing home documentation, medical records retrieval, etc.
• Perform in-depth provider claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency.
• Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements.
• Cook up documents for the Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments.
• Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.
• Review monthly capitation payments in accordance with contractual obligations.
• Develop monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirements and identify areas for improvement.
• Provide productivity and issues reports for Management.
• Other duties as assigned.

Qualifications

• Education: Bachelor’s Degree, and/or equivalent work experience.
• Experience: A minimum of three (3+) years of credentialing experience. Preferred: Credentialing in a Healthplan setting.
• Microsoft Office/Suite Proficient (Excel, Outlook, Word, etc.).
• Highly Organized. Able to multitask efficiently and effectively.
• Solid problem solving and time management skills.
• Able to review and draft correspondence in email and word processing systems.
• Professional, Friendly, and Skillful Communication Skill Set.
• Licenses: None Required, Certified Provider Credentialing Specialist – Preferred.

Physical Requirements

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
• Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.).
• Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Pay

$75,000.00 - $85,000.00