Credentialing Analyst, Infusion Clinics/Nursing

Elevance Health; Florida; Hybrid; USD 60,000 - 80,000; Full time

Job summary

Elevance Health is seeking a Credentialing Analyst to support infusion clinics and nursing credentialing with hybrid in-office requirements. The role involves audits, file reviews, performance analysis, and engaging with physicians and credentialing staff to resolve issues.

The position emphasizes regulatory compliance, network participation, and accreditation readiness, with a strong workflow in credentialing operations and data management.

Qualifications

• Requires a high school diploma or equivalent and at least 3 years in a managed care environment or equivalent background.
• Preferred Certified Provider Credentialing Specialist certification and related coursework.
• Experience handling credentialing files, renewals, and regulatory requirements.

Responsibilities

• Performs credentials file audits for timeliness, quality, and policy adherence.
• Reviews files for accuracy and completeness for Medical Director and Credentials Committee.
• Analyzes performance data to standards.
• May perform site visits to provider offices for network participation.
• Interacts with physicians, office managers, and credentialing staff to obtain information.
• Uses internal systems and runs reports to resolve credentialing questions.
• Monitors license actions, complaints, and sanctions for Manager review.
• Prepares documentation for Medical Directors' off-cycle reviews.
• Maintains provider peer review data in the credentialing database.
• Supports and tracks provider appeals process.
• May oversee delegation activities.
• Participates in accreditation survey prep via data entry and reporting.

Skills

Credentialing audits

Data analysis

Provider relations

Site visits

Education

High School Diploma

Certified Provider Credentialing Specialist

Tools

PECOS processing

NPPES updates

License tracking tools

Job description

Credentialing Analyst, Infusion Clinics/Nursing

Hybrid: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law

The Credentialing Analyst, Infusion Clinics/Nursing performs more complex activities in support of provider credentialing to include additional research, auditing, managing credentialing appeals, special projects, delegation oversight, and site visits.

How you will make an impact:

• Performs credentials file audits to ensure timeliness of processing, quality of documentation, and adherence to company and department policies.
• Performs quality review of files to determine accuracy and completeness of all necessary documentation for Medical Director and Credentials Committee.
• Analyzes performance data to predetermined standards.
• May also perform site visits of provider offices for participation in networks.
• Interacts with physicians, office managers, credentialing staff from other organizations to obtain information, provide status updates, research issues necessary for Credentials Committee review.
• Utilizes internal systems and runs reports/queries to research provider questions and resolve issues.
• Monitors license actions, complaints, and sanctions and obtains necessary information for Managers review.
• Prepares documentation for Medical Directors consideration of off-cycle review.
• Maintains provider peer review information on the credentialing database system.
• Supports and tracks provider appeals process.
• May assume responsibility for delegation oversight activities.
• Participates in accreditation survey preparation via data entry, reporting, and acting as task force liaison.

Minimum Requirements:

Requires a H.S. diploma or equivalent and minimum of 3 years experience in a managed care environment; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Knowledge of Medicaid, Medicare, managed care, and PBM providers.
• Experience administering provider/pharmacy credentialing and re-credentialing to meet regulatory, accreditation (e.g., URAC/ACHC), and managed care plan requirements.
• Experience tracking, organizing, and maintaining credentialing files and time-sensitive renewals (electronic and paper), ensuring accuracy and confidentiality.
• Experience serving as a credentialing troubleshooter, resolving payer/PBM-related issues and credentialing delays.
• Experience managing state Medicaid processes (new applications, renewals/revalidations), including portal maintenance, user access administration, and pulling remits as needed.
• Experience with Medicare PECOS processing, NPI (NPPES) updates, and maintaining NCPDP profiles for multiple pharmacy sites.
• Experience coordinating pharmacy site and pharmacist licensing (new applications, renewals, Pharmacist-in-Charge changes) and maintaining license tracking tools.
• Experience supporting payer and compliance documentation needs (e.g., Certificates of Insurance, Fraud/Waste/Abuse attestations, credentialing document collection for applications/RFPs) and collaborating with billing, clinical, and admissions teams.
• Certified Provider Credentialing Specialist and college course work.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.