Credentialing Operations Specialist

Avera Health Plans Inc; Sioux Falls (SD); On-site; USD 30,000 - 41,000; Full time

Benefits offered by this job

PTO from day 1

Career development mentorship

Job summary

Avera Health Plans is seeking a Credentialing Operations Specialist to coordinate provider credentialing and enrollment activities in compliance with NCQA and state/federal requirements. You will review applications, resolve issues with providers and internal teams, and support audits.

Responsibilities include maintaining credentialing data, assisting in committee file preparation, and ensuring timely, compliant communications regarding provider status.

Qualifications

• Associate's degree required; 1-3 years credentialing experience preferred.
• Knowledge of NCQA credentialing standards and state/federal laws.
• Experience with provider enrollment and contracting processes.
• Strong attention to detail and effective communication skills.

Responsibilities

• Coordinate initial enrollment and re-enrollment for providers and facilities.
• Review credentialing applications for NCQA compliance and completeness.
• Prepare files for Medical Director and credentialing committee review.
• Maintain credentialing data and respond to applicants and providers.

Skills

Credentialing experience

Provider enrollment

Communication

Attention to detail

Education

Associate's degree

Bachelor's degree

Tools

Credentialing software

Enrollment systems

Job description

Location:Avera Health PlansWorker Type:RegularWork Shift:Primarily days with possible weekends/evenings/holidays (United States of America)Pay Range:The pay range for this position is listed below. Actual pay rate dependent upon experience.$22.00 - $29.50Position HighlightsThis is a brand-new role! Avera Health Plans is expanding our credentialing services.You Belong at AveraBe 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 OverviewThe 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 doKnowledge 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 QualificationsThe 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) orCertified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)Expectations and StandardsCommitment 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 SomeAvera 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 retirementCareer development guided by hands-on training and mentorshipAvera 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. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail].