Specialist, Credentialing Operations

$56,160 - $56,160/Yr

Evolent Health - Springfield, IL

Full-time - Entry Level

Springfield, IL

Professional, Scientific, and Technical Services

About the position

The Specialist, Credentialing Operations at Evolent Health is a dynamic role focused on ensuring that healthcare providers meet the necessary credentialing requirements. This position involves determining which provider types require credentialing, initiating the Primary Source Verification Process (PSV), and performing outreach to providers. The Specialist will also be responsible for administrative auditing and maintaining provider data within the credentialing platform. Reporting to the Associate Director of Credentialing Operations, this role is integral to the overall credentialing process and requires collaboration with the Provider Data Management (PDM) team through a Jira ticketing system. In this position, the Specialist will manage credentialing and re-credentialing files, ensuring compliance with NCQA guidelines as well as partner-specific credentialing policies and procedures. The role includes ongoing monitoring of exclusions, sanctions, and adverse events, and the Specialist will represent the Credentialing department in meetings, delivering special projects and maintaining concurrent projects as assigned. Establishing and maintaining excellent relationships with both internal and external stakeholders is crucial, as is the ability to communicate effectively with the leadership team. The Specialist will also be responsible for maintaining contractual service levels and operational agreements as applicable, and will work with various credentialing and provider data management systems, including CAQH, Credentialing Systems, SPayer, Symplr, and Power BI Tool.

Responsibilities

• Determine provider types who require credentialing.
• Initiate the Primary Source Verification Process (PSV).
• Perform provider outreach and administrative auditing.
• Maintain provider data within the credentialing platform.
• Manage credentialing and re-credentialing files, including Type I and Type II files.
• Comply with NCQA credentialing and recredentialing guidelines.
• Adhere to partner-specific credentialing policies and procedures.
• Monitor exclusions, sanctions, and adverse events on an ongoing basis.
• Represent the Credentialing department in meetings and deliver special projects.
• Establish and maintain excellent relationships with internal and external stakeholders.
• Maintain contractual service level and operational level agreements as applicable.
• Maintain credentialing and provider data management systems.

Requirements

• Bachelor's Degree or equivalent years of work experience.
• Excellent verbal and written communication skills.
• Detail-oriented with good organizational skills.
• Ability to work in an agile space and adapt to fluctuating situations.
• Takes initiative and works independently.
• Ability to time manage and reprioritize tasks/projects as appropriate.
• Proficiency in Microsoft Office Suite, including Word, Excel, PowerPoint, and Outlook.

Nice-to-haves

• Experience with Counsel of Affordable Quality Healthcare (CAQH), Credentialing Systems, SPayer, Symplr, and proprietary claims system.
• Minimum of two to three years' experience in healthcare related to credentialing, provider enrollment, provider services, and/or configuration.
• General understanding of US healthcare, Managed Care Organizations, Medicare, and/or Medicaid.

Benefits

• Comprehensive health insurance benefits.
• Bonus component based on pre-defined performance factors.