Curative, a fast-growing health insurance start up focused on employer sponsored commercial plans, is looking for an experienced health plan credentialing leader to manage the overall credentialing process.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES 

• Manage a relatively small but talented credentialing staff responsible for direct credentialing, both physician and facility and overseeing delegated credentialing entities.

• Work with our credentialing vendor on issues related to their software. Our credentialing software vendor also provides us with additional credentialing capacity to assist with volume surges.

• Work with our Operations and Technology teams to assure that provider data is accurately transmitted into the directory and claim system. Some experience with provider data maintenance is preferred.

• Maintaining, Tracking, and Managing rosters for accuracy and completeness for final reporting that is needed for timely setup for claims payment, member assignment, and directory display.

• Conduct audits to reduce errors and improve processes and performance, maintaining current provider data to ensure the quality of the network

• Coordinate delegation audits to ensure compliance with state, federal, and NCQA standards, including scheduling audits, accurately completing delegation audit tools, and reporting outcomes to management.

• Assist with out-of-state licensure applications for medical director for expansion (i.e., medical license).

• Participate in team meetings alongside other team members to discuss credentialing issues, provide feedback to support with suggestions for the development and improvement of workflow, and discuss process improvement changes

• Perform medical credentialing file/element investigation and primary source verification of provider and facility initial and re-credentialing applications, utilizing established standards, state regulatory, and NCQA requirements. Ensure timely compilation of applicant and verification elements to prevent any adverse outcomes or delays in processing applications/files.

• Prepares agendas and related material for all Credentialing Committee meetings, including transcribing, and maintaining minutes for such meetings, along with ensuring expeditious follow- through on action items and policy changes.

• Analyzing credentialing standards and developing criteria to ensure compliance; revising general aspects of the credentialing and privileging process as necessary; making recommendations for revisions in development, current operating environment standards and enhancements as appropriate to the current policies and procedures.

• Ongoing monthly monitoring to ensure the quality and safety of care to members. Also, monitors for sanctions and tracks complaints, adverse events, and quality issues against practitioners through monthly queries and reports.

• Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc).

• This position assumes and performs other duties as assigned.

QUALIFICATIONS  

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 accommodations may be made to enable individuals with disabilities to perform the essential functions:

• 3-5 years of credentialing leadership experience within a commercial health plan

• Experience managing a credentialing team

• Experience with delegated credentialing and direct credentialing, for both physician and facilities

• Strong computer skills and communication skills. 

• Some experience with provider data services or provider data maintenance  is preferred

• Experience with Medallion credentialing  platform is preferred 

EDUCATION and/or EXPERIENCE 

• Bachelor's degree (B. A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.

WORK ENVIRONMENT  

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this Job, the employee is regularly required to sit; use hands to operate a computer; talk; and hear. 

• For this position the percentage of expected Travel is: 5 % of the time