Credentialing Analyst

Jobtailor; North Carolina; On-site; USD 52,000 - 72,000; Full time

Job summary

Jobtailor is seeking a Credentialing Specialist to support licensing and credentialing for a national virtual provider group. You will audit credential files, review vendor documentation, and analyze performance against standards.

The role involves interacting with clinical staff and leadership, running system queries to resolve provider questions, and monitoring licensing actions for management review. A background in managed care and familiarity with credentialing tools are essential.

Qualifications

• H.S. diploma or equivalent.
• Minimum of 3 years' experience in a managed care environment.
• Familiarity with NPPES, PECOS, CAQH, and Medallion Platforms.
• Strong organizational and time management skills.
• Experience in NLC, Medicaid Provider Enrollment, and Provider Collaboration Agreement Management.
• Experience working with frontline providers.
• Must be within a reasonable proximity/commuting distance of one of the posting offices unless accommodation is granted as required by law.
• General business hours, Monday through Friday.
• Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided.

Responsibilities

• Support overall licensing and credentialing efforts for a national virtual provider group
• Perform credential file audits for timeliness, documentation quality, and policy adherence
• Review files for accuracy and completeness of documentation from associated vendors
• Analyze performance data against predetermined standards
• Interact with internal clinical frontline staff and leadership to obtain information, provide status updates, and research issues for Credentials Committee review
• Use internal systems and run reports/queries to research provider questions and resolve issues
• Monitor license actions, complaints, and sanctions and obtain information for Managers' review
• Perform additional research, auditing, credentialing appeals management, special projects, delegation oversight, and site visits

Skills

Organizational Skills

Time Management

Interpersonal Communication

Education

High School Diploma

Tools

NPPES

PECOS

CAQH

Medallion Platforms

Job description

• Support overall licensing and credentialing efforts for a national virtual provider group
• Perform credential file audits for timeliness, documentation quality, and policy adherence
• Review files for accuracy and completeness of documentation from associated vendors
• Analyze performance data against predetermined standards
• Interact with internal clinical frontline staff and leadership to obtain information, provide status updates, and research issues for Credentials Committee review
• Use internal systems and run reports/queries to research provider questions and resolve issues
• Monitor license actions, complaints, and sanctions and obtain information for Managers' review
• Perform additional research, auditing, credentialing appeals management, special projects, delegation oversight, and site visits

Requirements

• H.S. diploma or equivalent
• Minimum of 3 years' experience in a managed care environment
• Any combination of education and experience providing an equivalent background
• Familiarity with NPPES, PECOS, CAQH, and Medallion Platforms
• Strong organizational and time management skills
• Experience in NLC, Medicaid Provider Enrollment, and Provider Collaboration Agreement Management
• Experience working with frontline providers
• Must be within a reasonable proximity/commuting distance of one of the posting offices unless accommodation is granted as required by law
• General business hours, Monday through Friday
• Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Core Competencies

Demonstrates expertise in credentialing and licensing processes within a managed care environment, with strong organizational and time management skills to ensure compliance and accuracy in documentation. Proficient in utilizing internal systems for data analysis and provider support.

Highest-signal resume keywords

• Credentialing Management
• NPPES Familiarity
• Medicaid Provider Enrollment
• Provider Collaboration Agreement Management
• Performance Data Analysis

Hard Skills

• Credential File Audits
• Documentation Quality Review
• Policy Adherence Monitoring
• Data Analysis
• Report Generation
• Auditing
• Appeals Management
• Site Visits

Soft Skills

• Organizational Skills
• Time Management
• Interpersonal Communication

Industry Keywords

• Managed Care
• Provider Group
• Credentialing Appeals
• License Actions
• Frontline Providers

Tools & Technologies

• NPPES
• PECOS
• CAQH
• Medallion Platforms