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Job Summary

Under the direction of Member Processing & Credentialing Manager and Credentialing Director :

Delegated Credentialing

• Performs provider credentialing and recredentialing services in compliance with Choice Health policies and procedures, the guidelines of the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), the legal requirements of the NC, SC, & VA Department of Insurance, as well as all other applicable State and Federal Laws.

• Responsible for creating and maintaining provider credentialing files, performing primary source verification on all credentials, and queryingtheNationalPractitionersDataBankforallChoiceHealthproviders.

• Ensures maintenance of Choice Health physician credentials with contracted managed care organizations and insurance companies.

• Provides support to physicians and practice manager in the application and credentialing process and acts as liaison with managed care organizations, self-insured businesses, insurance companies and Choice Health members.

• Responsible for volume management of initial applications that are received for ChoiceHealth members and assignment to a coordinator when deemed ready to process

• Manages requests for recredentialing applications for providers, monitors the status of providers due for recredentialing to ensure compliance with NCQA.

• Maintains training guidelines for new team members and works with existing team members when additional support or training is needed. Onboards new hires.

• Audits for initial and recredentialing applications prior to credentialing Committee approval.

• Prepares for and participates in Choice Health Credentialing Committee meetings. Timely prepares and maintains credentialing Committee minutes, submit monthly time sheets for both ChoiceHealth and CIN committee members. Submit requests to globally update credentialing database after each approval.

• Responsible for all delegated and non-delegated credentialing activities for Privia Medical Group.

• Adds new groups for ChoiceHealth and Privia to ACT. Manage large groups joining ChoiceHealth.

• Assists with assigning additional duties to credentialing coordinators that have shown consistency in accuracy of work and ability to take on new and additional responsibilities

• Works with the Department Director and Manager to identify and implement process improvement initiatives and efficiencies for the credentialing and enrollment processes of facilities.

Facility Credentialing

• Responsible for all high-level administrative duties and oversight reporting for Facility Credentialing Activities

• Responsible for managing and resolving prioritized or urgent issues and tasks within the department.

• Responsible for volume management of facility of applications and tasks within the department.

• Manages facility related special projects and distributes to team as necessary.

• Develop and monitor processes to ensure efficient success for our team.

• Considered first Point of Contact for all initial discussions of new hospitals/facilities including acquisitions, joint ventures.

• Works closely with billing team to ensure applications submitted are in compliance with billing standards.

• Works with the Department Director and Manager to identify and implement process improvement initiatives and efficiencies for the credentialing and enrollment processes of facilities.

Come join a remarkable team where quality care meets quality service, in every dimension, every time.

Let Novant Health be the destination for your professional growth.

At Novant Health, one of our core values is diversity and inclusion. By engaging the strengths and talents of each team member, we ensure a strong organization capable of providing remarkable healthcare to our patients, families and communities. Therefore, we invite applicants from all group dynamics to apply to our exciting career opportunities.

Responsibilities

It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience in every dimension, every time.

+ Our team members are part of an environment that fosters team work, team member engagement and community involvement.

+ The successful team member has a commitment to leveraging diversity and inclusion in support of quality care.

+ All Novant Health team members are responsible for fostering a safe patient environment driven by the principles of "First Do No Harm".

Qualifications

+ Education: High School Diploma or GED, required. Associate’s Degree, preferred.

+ Experience: Minimum of five years’ experience in performing credentialing services either for a medical facility, physician office, managed care company, or insurance company, required. Seven five years’ experience in performing credentialing services either for a medical facility, physician office, managed care company, or insurance company, preferred.

+ Licensure/Certification: CPCS, CPES, or equivalent certification, required.

+ Additional Skills (required): Proficiency in computer word processing, spreadsheet and database applications. Effective verbal, non-verbal and written communication skills. Skills in establishing and maintaining an effective relationship with physicians practice management and insurance/governmental agency representatives. Strong organizational skills, ability to adhere to deadlines and protocols. Ability to work under pressure and react calmly and effectively in difficult situations. Ability to learn and maintain knowledge of applicable governmental regulations and protocols. Ability to perform in a fast-paced, multi-task environment with flexibility as needed. Ability to be a team player and take initiative.

Job Opening ID

78604