Essential Job Functions
* Adhere to NCQA guidelines.
* Audit Provider Licensure Files to NCQA guidelines.
* Pull On-Going Files in accordance to NCQA.
* Understanding of Initial and Re-Credential Delegated files.
* Delegated Credentialing Payer Submissions.
* Prepare and distribute facility and provider applications to payers.
* Coordinate, monitor and maintain all credentialing and re-credentialing processes.
* Upload and update the system with new documents.
* Ongoing interaction with payers.
* Assist offices and internal departments with credentialing issues.
* Must be able to utilize the licensure portals.
* Source for effective dates from the payers.
* Notify relevant parties of effective dates.
* Keep records in licenses, credentials and insurance contracts.
* Responsible for all insurance changes.
* Respond to payers in a timely manner.
* Responsible for tracking provider renewals.
* Assess Monthly/Quarterly payer Directory updates.
* Communication with providers as needed.
* Rewrite policy and procedures
* Responsible for ensuring thorough preparation of documentation, reports, and any other information needed for regulatory and NCQA audits related to delegation oversight.
* Confirm delegated provider credentialing audits performed by the delegated credentialing team for initial, annual, and interim assessments in accordance with Joint Commission, NCQA, CMS, state and federal requirements
* Ensure NAH delegated credentialing process meets provider customer expectations using reports and trend analysis.
* Ensure annual delegated credentialing audit timeliness and corrective action plans are met. Manage credentialing rosters, reports, and delegated compliance of NAH Delegated Providers. Communicate as a liaison for Delegated Providers and internal partners.
* Manage and assist in the negotiation of delegated agreements.
* Maintain working knowledge of regulatory credentialing requirements
* Other projects as assigned.
Compliance and Safety
* If required for position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
* Completes all company mandatory modules and required job specific training in the specified time frame.
* Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
* Responsible for maintaining up-to-date knowledge of cybersecurity trends, developments, best practices and regulatory changes.
