Specialist, Credentialing Operations

$56,160 - $56,160/Yr

Evolent Health - Nashville, TN

Full-time

Nashville, TN

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 compliant with various guidelines. This dynamic 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. This role is essential in supporting the overall mission of Evolent to connect fragmented healthcare systems and ensure high-quality care for individuals with complex health conditions. In this position, the Specialist will collaborate closely with the Provider Data Management (PDM) team, utilizing a Jira ticketing system for efficient communication and task management. The responsibilities include managing credentialing and re-credentialing files, ensuring compliance with NCQA and partner-specific guidelines, and conducting ongoing monitoring of exclusions, sanctions, and adverse events. The Specialist will represent the Credentialing department in meetings, manage special projects, and maintain excellent relationships with both internal teams and external partners. The role requires a proactive approach, as the Specialist will need to adapt to fluctuating situations and manage multiple projects simultaneously. Excellent communication skills are essential for effectively conveying information to the leadership team and ensuring that service level agreements are met. The position also involves maintaining 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 ticket intake and triage for internal and external submissions.
• Handle 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.
• Conduct ongoing monthly monitoring of exclusions, sanctions, and adverse events.
• Represent the Credentialing department in meetings and manage special projects.
• Establish and maintain excellent relationships with internal and external stakeholders.
• Maintain contractual service level and operational level agreements.
• Manage 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 strong organizational skills.
• Ability to work in an agile environment and adapt to changing situations.
• Proactive and able to work independently.
• Strong time management skills and ability to reprioritize tasks as needed.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, 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, or provider services.
• General understanding of US healthcare, Managed Care Organizations, Medicare, and/or Medicaid.

Benefits

• Comprehensive health insurance benefits.
• Bonus component based on predefined performance factors.