Specialist, Credentialing Operations

$56,160 - $56,160/Yr

Unclassified - Pierre, SD

Full-time

Pierre, SD

About the position

Your Future Evolves Here. Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of the fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and the autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. The Specialist, Credentialing Operations will be a dynamic role that will encompass determining provider types who require credentialing, initiating the Primary Source Verification Process (PSV), performing provider outreach, and administrative auditing. This position reports to the Associate Director, Credentialing Operations. The Specialist, Credentialing Operations team collaborates with the Provider Data Management (PDM) team through our Jira ticketing system.

Responsibilities

• Maintenance of provider data within the credentialing platform.
• Ticket intake and triage for internal/externally submitted tickets.
• Responsible for credentialing and re-credentialing files, including both Type I and Type II files.
• Maintain working knowledge of and comply with NCQA credentialing and recredentialing guidelines.
• Maintain working knowledge of and comply with partner specific credentialing and recredentialing guidelines, policies, and procedures.
• Ongoing monthly monitoring of exclusions, sanctions, and adverse events.
• Represent Credentialing department in meetings and delivering special projects and maintaining concurrent projects as assigned.
• Establishing and maintaining excellent relationships, internally and externally including communication to the leadership team.
• Maintain contractual service level and/or operational level agreements, as applicable.
• Maintenance of credentialing and provider data management systems, including the Counsel of Affordable Quality Healthcare (CAQH), Credentialing Systems, SPayer, Symplr and proprietary claims system and Power BI Tool.

Requirements

• Bachelor's Degree or equivalent years of work experience - Required.
• Excellent verbal and written communication skills - Required.
• Detail oriented with good organizational skills - Required.
• Ability to work in an agile space and adapt to fluctuating situations - Required.
• Takes initiative and works independently - Required.
• Ability to time manage and reprioritize tasks/projects as appropriate - Required.
• Microsoft Office Suite, including Word, Excel, PowerPoint, Outlook - Required.
• Counsel of Affordable Quality Healthcare (CAQH), Credentialing Systems, SPayer, Symplr and proprietary claims system and Power BI Tool - Preferred.
• Minimum of two to three years' experience in healthcare field related to credentialing, provider enrollment, provider services, and/or configuration - Preferred.
• General understanding of US health care, Managed Care Organizations, Medicare and/or Medicaid - Preferred.

Nice-to-haves

• Experience with CAQH and credentialing systems.
• Knowledge of Medicare and Medicaid processes.

Benefits

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