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Credentialing Administrator in Boston, MA at Beacon Health Options

Date Posted: 4/11/2019

Job Snapshot

Job Description

ABOUT THE POSITION

Responsible for all facets of the credentialing process including, but not limited to, knowledge of Beacon Health Options/client specific criteria, accreditation standards (i.e. NCQA, URAC, and JCAHO), credentialing law, legal issues, state statutes, CMS requirements, Federal regulatory compliance, external reporting requirements related to quality of care issues/adverse incidents, and in depth knowledge of the credentialing policies and procedures including support of the credentialing committees ((Local Credentialing Committees (LCC), National Credentialing Committee (NCC)) and the fair hearing process.

Position Responsibilities:

  • Responsible for supporting the credentialing process by maintaining primary accountability for at least one major function outlined below in addition to maintaining backup support and/or partial accountability for two or more major functions outlined below, for which they are fully trained:
    • Conducting investigation and information gathering when outliers are present (i.e. malpractice claims/judgments, disciplinary action and/or sanctions are pending or present on an applicant or a network provider) during the credentialing/re-credentialing process or as identified in between credentialing cycles.
    • On-going monitoring of sanctions by maintaining and reviewing the disciplinary action/sanction reports released by the State licensure boards or the List of Excluded Individuals and Entities (LEIE) monthly database released by the Office of the Inspector General within the department’s required time frame (30-days from release of the entity).
    • Identification of providers who require a site visit and coordinating the on-site treatment record keeping practice review with the Provider Relations Department and the Credentialing Specialist responsible for the file.  This includes scoring the tool once it is returned to the department and coordinating notification to the provider, Provider Relations and the Credentialing Specialist upon completion. 
    • Assists the Credentialing department in preparing provider files for Committee review.  This includes performing quality review of the provider files processed by Credentialing Specialist, updating the credentialing system, report generation, preparation and/or presentation of advisory related issues, meeting documentation preparation, attending or chairing the committee meeting, documenting the decision and coordination with appropriate parties/entities to bring file to completion or to the next step in the credentialing process. The oversight of the committee includes reviewing the materials presented for accuracy and inclusion of all relevant/required information.
    • Assists department in preparing for delegation oversight audits, including NCQA, State entities and/or client delegation oversight audits.  The staff member may also participate in performing delegation oversight activities, which include reviewing delegate’s compliance with Beacon Health Options and accreditation guidelines.
  • Responsible for accurate and timely composition of the committee advisory forms which includes gathering pertinent data necessary to make an informed decision.  The advisory form includes details outlining the situation/issue and the appropriate recommendations based on the internal hierarchical process.  The Credentialing Coordinator may be required to read and interpret legal documents (from attorneys, courts and State licensure boards) to create an accurate summary of all relevant/factual information for the Committee to render an informed, effective decision.
  • Responsible for the daily activities of the site visit process, including identification of providers who will receive a site visit, schedule site visit, scoring of the tool and notification to the provider and the Provider Relations department in a timely and accurate manner.  This task may require coordination with a third party site visit vendor.  Responsible for identification and coordination of reports and completion of the system tracking mechanism in order to closely monitor timeliness requirements.
  • Assists department in performing quality oversight of the Credentialing Specialist by conducting random provider file audits, following department workflow and established random sampling procedure.  Staff member assists management team to track and identify trends to recommend redial action and/or changes in the established procedures.
  • Responsible for acting as a liaison to the LCC, NCC, PAC and the fair hearing process.  Assists the department in coordinating file preparation for LCC/NCC/PAC/Medical Director review and decision in a timely and accurate manner.  Responsible for ensuring files are processed according to department established timelines, if problems arise, the issue is immediately escalated to the appropriate manager or responsible party.
  • Exhibits professional oral and written communication skills.  Must be able to speak persuasively, effectively and present information before groups of employees, managers/VPs, clients, internal and external customers, committee members and/or legal counsel.  Ability to speak persuasively, effectively present information, and respond to questions from groups of managers/VPs, clients, internal customers, Legal Counsel and the provider.  Must possess high level of service oriented skills and able to maintain calm in high pressure environment.
  • Maintains strict confidentiality of all job related information by ensuring the information is shared with appropriate parties; never divulge information obtained via the investigation process when prohibited by state or Federal law or to individuals not directly involved in the credentialing decision process, including provider’s office staff.  Information may be released to provider according to department’s policies and procedures and must be given in writing.
  • Takes on responsibility for challenging or special accounts and processes.  Can participate in implementation planning meetings, service center meetings (conference calls) as an SME, assist with workflow development and/or implementation, and other committee or quality related activities.
  • Manage and maintain the integrity of the provider credentialing database including data entry of credentialing information which requires full comprehension and application of all applicable proprietary software applications (Connect products) in addition to utilization of multiple job aids and/or Access databases.
  • Display reasoning ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form.  Ability to deal with complex issues while maintaining a flexible positive, cooperative demeanor.  Flexibility and adaptability to meet periodic changes in departmental needs.  Promotes direct, honest, open and timely communication throughout the company.  Does not filter or misrepresent information
  • Ability to work in a fast paced environment and prioritize multiple demands. Demonstrate exceptional organizational skills, capable of prioritizing responsibilities, multi task, detail oriented, and ability to work independently with limited supervision.

Position Requirements:

Education: Bachelors’ degree preferred. High School Diploma or Equivalent required.

Licenses: Encouraged to obtain CPCS Certification prior to or upon promotion to a Credentialing Administrator.

Relevant Work Experience: Minimum of 3 years working experience in the insurance or finance industry, with one year of healthcare experience preferred. Six months experience in credentialing required.

To Apply:

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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment.  EOE/AA/M/F/Veterans/Disabled