Credentialing Coordinator (Hybrid - Troy, MI) - Health Alliance Plan

Clinical/Allied Health Credentialing Specialist

Under minimal supervision, responsible for initial and re-credentialing functions including completion of the application and verification process, Credentialing Committee preparation and follow-up, coordination with contracting and interaction with practitioners, office staff and network representatives.

Principle Duties and Responsibilities:

• Responsible for all aspects of the CAQH credentialing application and verification process for initial and re-credentialing requests. Assess completeness of information and practitioner qualifications relative to regulatory standards and guidelines including NCQA, CMS, MDCH and HAP's established standards; maintain credentialing files according to regulatory standards and guidelines including NCQA, CMS MDCH, and HAP's standards.
• Assure all practitioner data is accurate and up-to-date in the CACTUS/Symplr Provider credentialing software application, including generating and monitoring reports.
• Responsible for on-going communication with internal and external customers. Respond to all correspondence within 48 hours. Consult with management quickly if unable to resolve within expected timeframe.
• Coordinate, implement, analyze and close annual delegated audits, as assigned. As issues are identified, resolution must be documented and completed in a timely manner and in accordance with regulatory standards.
• Organize and maintain practitioner files following confidentiality guidelines.
• Extract and present key information including CAQH credentialing application and credentials, and identification of potential practitioner issues to facilitate the Credentials Committee decision-making process.
• Maintain tickler systems for follow-up of unanswered correspondence to maintain department standards for application processing time.
• Participate in all data integrity projects, as identified.
• Provide cross-coverage for other analysts, as needed.
• Perform other related duties as assigned.

Education/Experience Required:

• Associate's degree in business, health care or related field or four (4) years of related experience in healthcare industry, managed care experience in lieu of degree.
• Bachelor's degree in business, health care or related field preferred.
• Minimum of two (2) years of experience in managed care experience.
• Minimum of two (2) years of experience in physician credentialing.
• Minimum of two (2) years of CACTUS/symplr Provider physician credentialing software experience preferred.
• Knowledge of Council for Affordable Quality Healthcare (CAQH) Practitioner Application preferred.
• Ability to work under minimal supervision.
• Ability to perform detail work efficiently and with a high degree of accuracy.
• Excellent problem-solving skills.
• Highly organized.
• Ability to initiate and coordinate multiple projects simultaneously.
• Excellent verbal communication skills.
• Ability to interpret information and make judgments quickly.
• Ability to interact professionally with practitioners and other external customers.
• Strong quantitative and analytical skills.
• Computer proficient in Microsoft Office including; Word and Excel.
• Knowledge of the principles and practices of credentialing is highly desirable.

Certifications/Licensures Required:

• Certification as CPCS (Certified Provider Credentialing Specialist) or CMSC (Certified Medical Staff Coordinator) preferred.

Additional Information:

• Organization: HAP (Health Alliance Plan)
• Department: Provider Network Operations
• Shift: Day Job
• Union Code: Office/Non-Exempt, HAP