Under direction from the Credentialing Supervisor, the Credentialing Specialist is responsible for ensuring all THP affiliated physicians and other independent practitioners and allied providers are qualified to provide health care services to members in accordance with THP’s policies and procedures, state laws and/or regulatory requirements (e.g. NCQA). Practitioners are recredentialed at least every three years or more frequently as required.

 

Key Responsibilities/Duties – what you will be doing

Responsible for maintaining and processing physician and provider credentialing information for new and established health plan practitioners in accordance with THP’s policies and procedures, state laws and regulatory agencies, including but not limited to:

• Assessment of adequate and accurate information for participation in THP, including a limited knowledge of provider contract information
• Accurate and timely entry of initial and existing credentialing applications into the credentialing information system (Cactus)
• Verification through various sources of necessary licenses, board certification, etc.
• Review and report of adverse information received through National Practitioner Data Bank (NPDB), state and federal sanctions
• Retrieval of missing and/or expired information/documentation required for credentialing;
• Act as resource for physician and provider questions relating to certification and/or credentialing process;
• Identify for Credentialing Supervisor those issues of broader complexity or sensitivity that may require further action by a Medical Director or other outside source.
• On a daily basis, prepare files that Meet Credentialing Criteria for review by the Credentialing Compliance Coordinator and/or Supervisor and presentation to daily Medical Director file review.
• Prepare files that may not Meet Credentialing Criteria for review by the Medical Directors and/or Senior Credentialing Specialist and/or Supervisor and presentation to the Quality of Care Committee (QOCC), including report of adverse information.
• On a daily basis, process all practitioners under the terms and conditions of the entities’ agreement, including files credentialed through a Certified Verification Organization (CVO).
• Participate in task forces and/or other meetings as assigned and execute other responsibilities as assigned.
• Other tasks as assigned.

Qualifications – what you need to perform the job

EDUCATION:

 

• B.A./B.S. or equivalent in health care or related field preferred.

EXPERIENCE:

 

• Academic concentration in health care or 1-2 years experience in health care field.
• Experience with personal computer required. (Experience with provider credentialing preferred.)
• Knowledge of Windows 95, Microsoft Word and Excel preferred.

COMPLEXITY

• All information (written, verbal, electronic, etc.) Ability to appropriately identify emergency situations and follow the appropriate protocol.
• Must have the ability to maintain and manipulate a complex credentialing information system.
• Must be able to prioritize multiple tasks and achieve deadlines.
• Must have ability to adapt to changing environment.
• Strong written and verbal skills are necessary. Individual must possess initiative, judgement, exceptional organizational skills and keen attention to detail.
• Must be able to work and process time-sensitive information.

PERSONAL CONTACTS

• Must be able to work cooperatively as a team member.
• Frequent written and verbal contact with physicians, office staff and internal customers. Must use discretion when dealing with Plan providers and all other departments.

CONFIDENTIAL DATA

• All information (written, verbal, electronic, etc.) that an employee encounters while working at TAHP is considered confidential.
• Requires confidentiality with regard to provider information and credentialing documents.

MENTAL/PHYSICAL REQUIREMENTS

• Fast paced office environment handling multiple demands. Must be able to exercise appropriate judgment as necessary.
• Requires the ability to use PC. Ability to transfer information from paper-form to on-line data is necessary. In the absence of specific direction, must be able to prioritize workload. Work requires ability to use independent judgment and discretion in decision-making which may impact the organization.

PHYSICAL WORK ENVIRONMENT

• Work is done either remotely or in the home office in a cubicle area with other employees.

 

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

TalentBoost is now Ignyte AI.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R6557

Posted On: Tuesday, May 23, 2023