Resp & Qualifications
PURPOSE:
Provides analysis and reporting for practitioners credentialing and institutional credentialing and ancillary providers by obtaining provider related data; analyzing gaps in provider records; designing solutions; carrying out necessary credentialing activities. This role using expertise in credentialing operations, analysis and reporting skills sets to credential practitioners, institutional providers and ancillary providers for network participation with CareFirst BlueCross BlueShield and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.
ESSENTIAL FUNCTIONS:
- Research and improve practitioner, institutional and ancillary provider information by examining and researching provider data gaps by obtaining facts, analyzing problems/identifying root cause recommending and facilitating resolution. Ensures compliance of provider records through continuous review and analysis, updating and maintaining of current required primary source verification documentation, and ongoing communication with providers to obtain reverification documentation. Maintains the provider file, and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities.
- Supports network operations systems by providing operating information to providers and internal stakeholders; answering questions; providing education and training as needed. Ensures accurate and timely day to day processing of new providers in accordance with regulatory requirements and timeframes, improves provider experience, and supports Provider Information & Credentialing department on inventory control.
- Contributes to operations analysis and organization success by welcoming related, different, and new requests; helping others accomplish job results, development of Standard Operating Procedures (SOP) and other essential documentation. Produces weekly inventory reporting, identifying trends and issues, developing recommendations to improve processes.
- Verifies operations systems by developing testing methods; conducting and documenting tests.
- Improves operations analysis job knowledge by attending training sessions; reading technical publications.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Business Administration OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 2 years experience in (level 2 or above) operational role.
Preferred Qualifications: Certified Provider Credentialing Specialist (CPCS).
Knowledge, Skills and Abilities (KSAs)
- Ability to recognize, analyze, and solve a variety of problems.
- Highly proficient in Microsoft Office and similar applications.
- Organized, detail-oriented while meeting strict deadlines.
- Excellent communication skills both written and verbal.
- Demonstrate ability to work independently.
- Knowledge of NCQA standards.
- Ability to follow reference materials/SOPs to reduce risk and ensure provider data accuracy and quality.
- Highly proficient in Microsoft Office and similar applications.
- Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes.
- Knowledge of medical terminology.
Salary Range: $44,568 - $88,517
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate 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 associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship.
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