Credentialing Operations Specialist

Sioux Center Health; Sioux Falls (SD); On-site; USD 30,307 - 41,328; Full time

Benefits offered by this job

PTO from day 1

5% employer 401(k) match

Career development

Job summary

Avera Health Plans is expanding our credentialing services with a brand-new Credentialing Operations Specialist position in Sioux Falls, SD. You will coordinate provider credentialing and enrollment activities, ensuring NCQA, state, and federal compliance while supporting audits and communications with providers.

The ideal candidate will review applications for accuracy, partner with providers and internal teams to resolve issues, maintain credentialing data, and assist in committee

Qualifications

• Associate degree or equivalent combination of education and experience.
• 1–3 years credentialing experience, provider enrollment, provider contracting, compliance, or related administrative experience.

Responsibilities

• Coordinate initial enrollment and re-enrollment for providers and facilities contracted with Avera Health Plans.
• Review credentialing applications for NCQA compliance and ensure completeness.
• Verify PSV with CVO and document red flags.
• Coordinate file reviews with Medical Director and gather required information.
• Prepare Credentialing Committee files and support audits.

Skills

NCQA credentialing

Provider enrollment

Compliance awareness

Data entry

Communication skills

Education

Associate degree

1–3 years credentialing experience

Job description

Location: Avera Health Plans

Worker Type: Regular

Work Shift: Primarily days with possible weekends/evenings/holidays (United States of America)

Pay Range: $22.00 - $29.50

The pay range for this position is listed below. Actual pay rate dependent upon experience.

Position Highlights

This is a brand-new role! Avera Health Plans is expanding our credentialing services.

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The Credentialing Operations Specialist is responsible for coordinating provider credentialing and enrollment activities in compliance with NCQA, state, and federal requirements. Reviews applications for accuracy and completeness, partners with providers and internal teams to resolve issues, and prepares files for Medical Director and committee review. Maintains credentialing data, supports audits, and ensures timely, compliant communication regarding provider status.

What you will do

• Knowledge of NCQA Credentialing standards and all applicable state and government laws regarding credentialing and applies them to the credentialing process.
• Coordinates the initial enrollment and re-enrollment process for providers and facilities contracted with Avera Health Plans.
• Reviews initial and reappointment credentialing applications to ensure compliance with NCQA process. Ensures application completeness and works with providers to gather missing or incomplete information.
• Reviews credentialing applications returned from the Central Verification Organization (CVO) to ensure Primary Source Verifications (PSV) were done accurately and timely, consistent with NCQA, state and federal credentialing requirements. Accurately determines and documents clean vs red flag files.
• Coordinates with Medical Director for file review of clean and red flag files. Gathers additional information based on the Medical Directors feedback.
• Assists in monthly Credentialing Committee File preparation.
• Generates and sends out compliant communication to providers related to credentialing terminations, denials, and approvals consistent with Avera Health Plans policies and NCQA requirements.
• Performs accurate data entry and maintains enrollment records within the credentialing system and internal databases.
• Responds to applicants and current providers regarding the credentialing process and status.
• Serves as a resource to internal and external clients by answering credentialing questions, conducting audits, and doing file preparation for audits.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience

• Associate's Two-year college or technical school or an equivalent combination of education and experience.
• 1-3 years Credentialing experience, provider enrollment, provider contracting, compliance, advanced medical or administrative experience and/or training.

Preferred Education, License/Certification, or Work Experience

• Bachelor's In a related field of health information/healthcare or business.
• Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) or
• Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law.