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Credentialing Network Specialist

Company: Optum
Location: Tacoma
Posted on: November 22, 2020

Job Description:

JOB DESCRIPTIONCredentialing Network SpecialistDepartment: Practice SupportFLSA Classification: Non-exemptLocation: Tacoma, WAReports to: Provider Operations ManagerNorthwest Physicians Network is now offering qualified candidates an opportunity to join our team as a Credentialing Network Specialist. Our company values innovative problem solvers promote personal and professional growth and provides a supportive working environment that affords all of its employees a healthy work/life balance.The Credentialing Network Specialist works collaboratively with the Credentialing team processing and maintaining credentialing files for network participants to ensure participants are properly trained, licensed and certified as mandated by state and federal regulations.Northwest Physicians Network creates the opportunity for independent private practitioners to thrive in Washington State. By providing clinical integration support and data driven quality improvement, we have created a high value delivery network, making it possible for our providers to remain focused squarely on their patients.ESSENTIAL DUTIES & RESPONSIBILITIES

  • Conducts primary source verifications
  • Reviews credentialing applications and supporting documentation for completeness in accordance with Company policies, CMS and NCQA criteria and standards
  • Communicates with Network Development team and/or providers and facilities to request and obtain additional information as needed
  • Prepares and presents of monthly Credentials Committee documents
  • Performs data entry of credentials information, ensures accuracy of data, and conducts periodic audits to validate data
  • Researches and resolves credentialing issues that may impact patient assignment, authorizations and/or claims
  • Supports the monitoring of quality assurance and quality improvement activities for Company contracted providers and facilities.
    • Is the relationship manager and primary credentialing point of contact for specific health plan partners and sub-delegated groups.
    • Maintains data integrity through review and audits
    • Follows internal policies and procedures as they relate to direct and delegated credentialing contracts.
    • Provides overflow support to the Contact Center Outreach Program as may be required for NPN participating providers and their patients.KNOWLEDGE, SKILLS AND ABILITIES
      • Current knowledge of regulatory requirements regarding credentialing (CMS, NCQA, OIG, applicable Company policies and state and federal regulations)
      • Ability to represent Company as the authority on credentialing and delegated credentialing issues
      • Working knowledge of delegated health care delivery networks----------------------------------------------------------------------------------------
      • Demonstrated knowledge of PC applications such as Word, Excel, and Outlook
      • Demonstrated knowledge of credentialing software such as Cactus.
      • Skill and ability to communicate clearly and professionally in written or oral formats
      • Ability to identify problems, analyze data and recommend solutions
      • Ability to work with frequent interruptions--------------------------------------------------------------------------------------------------------
      • Ability to maintain confidential information in accordance with Company policies, state and federal regulations.----------
      • Ability to manage detail and work with accuracy--------------------------------------------------------------------------------------------------------------
      • Ability to acquire knowledge of technical resources within the organization to access information
      • Ability to work independently and assess appropriate information to be conveyed to different levels of management
      • Ability to establish and maintain cooperative working relationships with individuals at all levels including teammates from other teams. providers and clinic staff
      • Skill in working effectively under deadlines and changing prioritiesMINIMUM QUALIFICATIONSEducation: High School degreeExperience:--
        • 3 years of experience in credentialing within a healthcare organization
        • 2 years of experience using credentialing software, Cactus preferred
        • Obtain certification of Certified Provider Credentialing Specialist (CPCS) within two (2) years of employmentEQUIPMENT USEDOffice equipment, computerMENTAL & PHYSICAL DEMANDS/WORKING CONDITIONS
          • Mental Effort: Must be able to work effectively as a member of NPN team; work is detailed and complex with multiple competing priorities, deadlines and internal and external customers
          • Physical Requirements: Work is primarily in office environment requiring ability to see and hear and communicate
            • Working Conditions: Work is performed in an office setting; noise level may be moderate or loud on occasionThe job description does not constitute a written or implied contract of employment.-- NPN reserves the right to revise or change job duties and responsibilities as the need arises.--

Keywords: Optum, Tacoma , Credentialing Network Specialist, Other , Tacoma, Washington

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