This position is responsible for processing provider application for network entry and reappointment, including primary source verification of providers credentials according to Plans policy, NCQA standards and regulatory requirements, conduct site visits at provider offices for credentialing and re-credentialing, and maintain providers credentialing records between credentialing cycles.

• Intake of requests for credentialing and re-credentialing and ensure that all applicable documents have been received and initiate outreach to the provider for missing documentation
• Perform primary source verification of provider applications submitted for process for initial credentialing and re-credentialing according to regulatory requirements and company standards
• Provide status updates to providers on the progress of their initial credentialing and re-credentialing application
• Effective data entry of documentation from initial and re-credentialing applications in CACTUS and ensure accuracy of data entered for all providers
• Conducts self-reviews of initial and re-credentialing applications prior to submitting to credentialing committee to ensure standards are applied
• Manages and prioritizes assigned work to ensure compliance with regulatory requirements and departments goals are met compliance
• Conduct monthly checks of, or more often as appropriate, disciplinary action reports issued by State licensure bodies; Medicaid and Medicare exclusion and take appropriate action as defined in policy
• Conduct quality onsite assessment at provider offices as assigned
• Assist in audits of the Plan by regulatory agencies
• Assist in the oversight of delegated credentialing activities
• Initiate requests for updates to provider records in claims system when data discrepancies are identified during re-credentialing process
• Serve as team representative at internal meetings
• Maintenance of providers credentialing records between credentialing cycles

• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required:

• Associates degree in related field or sufficient work experience to equate to degree
• Minimum three (3) years credentialing experience, quality or provider operations
• Intermediate knowledge of Microsoft Office, including Outlook, Excel and Word
• Able to independently manage multiple tasks at any given time
• Excellent verbal and written communication skills in order to communicate in-person or telephonically with applicants, providers, etc.
• Ability to effectively communicate interdepartmentally to facilitate work flow
• Ability to work collaboratively with peers to support a team environment
• Ability to understand, interpret and apply regulatory guidelines and company policies and procedures to credential practitioners
• Strong attention to details
• Excellent organizational skills, including ability to prioritize work and handle multiple tasks simultaneously
• Ability to maintain accurate and detailed records
• Must be able to readily adjust to change and handle a rapid-paced environment while continuing to provide high-quality, efficient service
• Adherence to all confidentiality regulations and agreements
• Ability to travel. Must have access to reliable transportation. If using a personal vehicle, must have a valid drivers license and proof of insurance

Preferred:

• Ability to learn various software packages as necessary to perform job functions
• Knowledge of CACTUS software

Core Company-Wide Competencies:

• Communicate Effectively
• Respect Others & Value Diversity
• Analyze Issues & Solve Problems
• Drive for Customer Success
• Manage Performance, Productivity & Results
• Develop Flexibility & Achieve Change

Job Specific Competencies:

• Build Relationships & Cultivate Networks
• Collaborate & Foster Teamwork
• Plan & Organize

FDR Oversight:

• N/A

Flexible Work Arrangement:

• Yes, per department policy

Telecommuting Arrangement:

• No

Travel Expectations:

• N/A

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.