Specialist, Credentialing Operations

$56,160 - $56,160/Yr

Evolent Health - Tallahassee, FL

Full-time

Tallahassee, FL

Professional, Scientific, and Technical Services

About the position

The Specialist, Credentialing Operations at Evolent plays a crucial role in ensuring that healthcare providers are properly credentialed and that their data is accurately maintained within the credentialing platform. 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 compliance with various credentialing guidelines, including those set by the National Committee for Quality Assurance (NCQA) and specific partner requirements. This role is dynamic and requires a proactive approach to managing multiple projects and maintaining excellent relationships with both internal teams and external partners. In this position, the Specialist will collaborate closely with the Provider Data Management (PDM) team, utilizing a Jira ticketing system to manage ticket intake and triage for both internal and externally submitted requests. The Specialist will be responsible for maintaining credentialing and re-credentialing files, ensuring that all documentation is complete and compliant with established guidelines. Ongoing monitoring of exclusions, sanctions, and adverse events is also a key responsibility, as is representing the Credentialing department in meetings and delivering on special projects as assigned. The Specialist will need to maintain a working knowledge of various credentialing and provider data management systems, including the Counsel of Affordable Quality Healthcare (CAQH), Credentialing Systems, SPayer, Symplr, and proprietary claims systems. This role requires excellent communication skills, attention to detail, and the ability to work independently in an agile environment. The Specialist will also be expected to manage their time effectively, reprioritizing tasks and projects as necessary to meet operational goals and service level agreements.

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 ticket intake and triage for internal and external tickets.
• Responsible for credentialing and re-credentialing files, including Type I and Type II files.
• Comply with NCQA credentialing and recredentialing guidelines.
• Comply with partner specific credentialing guidelines, policies, and procedures.
• Monitor exclusions, sanctions, and adverse events on an ongoing basis.
• Represent the Credentialing department in meetings and deliver special projects as assigned.
• 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 health care, Managed Care Organizations, Medicare and/or Medicaid.

Benefits

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