GENERAL PURPOSE:

Responsible for reviewing and processing all provider applications and completeness, accuracy, and compliance with NCQA standards, policies and procedures, and applicable Federal and State regulatory guidelines. Conduct verification of credentialing elements through the use of system resources and approved departmental tools and document status within credentialing files and databases. Complete all initial and re-credentialing application functions in a timely and accurate manner for presentation to the Credentials Committee. Track and assure that all physicians and AHPs possess current licensure, DEA, and malpractice coverage. Database maintenance, filing, and other duties as assigned

DUTIES & RESPONSIBILITIES:

• Coordinates the initial and re-credentialing process for providers promptly
• Works independently with internal and external customers to research, resolve, and complete credentialing-related issues
• Communicates with physicians and their office staff, health plans, hospitals, and other provider organizations to provide primary source verification
• Maintains relationships with Providers, Provider office personnel, Health Plan’s Provider Relations Department to provide and/or obtain documentation pertinent to the timely and accurate completion of the delegated credentialing process
• Performs ongoing monitoring and assists in preparing documents and reports for committee meetings
• Tracks progress of working files to ensure submission to Credentialing Peer Review Committee promptly, to meet department timelines
• Coordinates the transfer of files ready for Credentialing Peer Review Committee review to the health plans regularly (monthly at minimum)
• Maintains current knowledge of state guidelines and regulatory requirements and all business rules about applicable health plans
• Maintains current knowledge of the credentialing process and applicable database system (CACTUS) changes
• Responsible for all data entry in the online queries and Credentialing database (CACTUS) On-going maintenance of the provider files and expired documents
• Maintain the security of the Credentialing files, databases, and other confidential data

QUALIFICATIONS:

• Minimum of High School diploma Associate’s degree or above preferred (in healthcare administration or related field)
• Two (2) or more years in a plan, hospital, managed care, or physician group credentialing environment Working knowledge of NCQA standards
• Knowledge of general Managed Care, Health Plan, and/or Physician Group operations

For individuals assigned to a location(s) in California, Bright Health is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $20.22 - $30.32 hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; up to 21 days of PTO, 10 paid holidays, plus 2 floating holidays per year; and a lifestyle spending account.