Sr. Credentialing Specialist

Location: 100% Remote with the possibility of being hybrid.

Most of the positions at YCCO are hybrid, meaning they have the flexibility to work both remotely and/or in-person.

Department: Heath Plan Operations FLSA Status: Exempt

Reports To: Manager of Provider Network Physical Strength: Light (L)

Learn more about Yamhill Community Care: click here

Summary

The Sr. Credentialing Specialist will develop and maintain positive relationships with physicians, providers, and practice managers within the Health Plan network while leading the credentialing process. Position interacts with physicians, directors, managers, and peers on a daily basis. This position is responsible for credentialing of Yamhill Community Care's (YCCO) managed care network providers (practitioners and institutions), and oversight of delegation of credentialing to provider groups. This position provides guidance, training, and mentorship of other staff in the performance of their responsibilities while overseeing efficiency and quality in operational processes.

Essential Duties

• Leads the credentialing process with the YCCO provider network.

• Manages all aspects of credentialing following National Committee for Quality Assurance (NCQA) and State of Oregon requirements, inclusive of Credentials Verification Organization (CVO) vendor oversight.

• Supports and facilitates the YCCO Credentialing Committee in the preparation, summarization of credentialing files requiring increased scrutinization for network participation approval.

Job Duties

• Manages the intake process for new providers, inclusive of but not limited to credentialing applications, provider rosters, pre-delegation questionnaires, and/or copies of State of Oregon Certificates of Approvals.

• Facilitates the processes to re-credential existing providers.

• Collects and upload provider credentialing applications, provider rosters, and/or Council for Affordable Quality Healthcare, Inc. (CAQH) accreditation IDs.

• Maintains accurate and up-to-date credentialing records in compliance with organizational policies and regulatory standards.

• Ensures managed care credentialing applications (practitioners and institutions) are completed and reviewed within Health Plan guidelines.

• Facilitates peer review of credentialing files, and audits performance.

• Leads the reappointment or initial credentialing process and monitoring work queues and process status measures.

• Develops workflows and file structure.

• Conducts meetings to ensure workload progress, resolve problems and deploy interventions to improve efficiency and maximize timeliness.

• Facilitates and maintains necessary documentation pertaining to provider operating under a delegated credentialing or State of Oregon Certificate of Approval, including coordination of delegation oversight.

• Liaisons with provider groups, office managers and providers regarding managed care credentialing applications, statuses and missing information.

• Educates provider group credentialing managers, office managers and providers regarding NCQA, YCCO, Center of Medicare & Medicaid Services (CMS), and State of Oregon requirements for credentialing.

• Documents and responds to provider issues as appropriate.

• Provides continuous education to physicians and other staff.

• Serves as resource for staff to clarify policies, procedures, and accreditation and regulatory standards.

• Supports staff in resolving complex credentialing issues and information discovery challenges.

• Submits progress reports to management, the Credentialing Committee, and the Compliance Committee as needed.

Essential Department & Organizational Functions

• Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.

• Participates in the preparation and submission of regulatory and contract required deliverables.

• Works closely with other YCCO departments, including Compliance to assist with audits; including the External Quality Review (EQR), as needed.

• Proposes and implements process improvements.

• Meets deadlines for completion of assigned responsibilities and projects.

• Maintains agreed upon work schedule with punctual, regular, and predictable attendance.

• Demonstrates cooperation and teamwork using a professional and respectful demeanor.

• Provides cross-training on specific job responsibilities.

• Meets identified goals that contribute to departmental goals.

• Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.

• Respectfully takes direction from Supervisor.

• Performs other duties as assigned.

Knowledge, Skills, & Abilities

• Strong understanding of credentialing processes, regulations, and accreditation standards.

• Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.

• Proficiency in credentialing software systems.

• Works closely with management in maintaining health plan regulatory compliance.

• Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.

• Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.

• Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.

• Ability to communicate both professionally and effectively in all forms of communication.

• Ability to work in an environment with diverse individuals and groups.

• Ability to remain flexible, positive, and adaptable.

Supervisory Responsibilities

This position has no supervisory responsibility.

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation(s) may be made to enable individuals with disabilities to perform the essential duties.

Education & Experience

Required:

• Bachelor's degree in business administration, health education, or related field

• Minimum of Two (2) years of experience in credentialing or provider enrollment, in the healthcare industry.

OR:

• Any combination of education and experience that would qualify candidate for the position.

Preferred:

• 2+ years of experience with Medicare and state Medicaid applications for physical and behavioral health in the State of Oregon.
• CAQH experience strongly preferred.

Certificates, Licenses and/or Registrations

Required:

• National Association Medical Staff Services (NAMSS) Certified Provider Credentialing Specialist (CPCS)

OR:

• National Association Medical Staff Services (NAMSS) Certification of Professional Medical Service Management (CPMSM)

OR:

• Achievement of certification (CPCS / CPMSM ) within 12 months of hire

Physical Demands & Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential duties of this position. The work environment characteristics described here are representative of those an employee encounters while performing the essential duties of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit, stand, walk, use hands and fingers, handle or feel, and reach with hands and arms. The employee is occasionally required to climb or balance, stoop, kneel, crouch or crawl. The employee may occasionally need to lift and/or move up to 25 pounds.

This position operates in a professional office environment and requires frequent use of standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Specific vision abilities required by this job include close vision, color vision, distance vision, depth perception, and ability to adjust focus. The noise level in the work environment is usually moderate.

This position may include occasional required or optional travel outside of the workplace, in which the employee's personal vehicle, local transit, or other means of transportation may be used.