Provider Credent Data Analyst

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 50,000 - 70,000; Full time

Job summary

A leading healthcare provider in Philadelphia is seeking a Credentialing Specialist to manage the credentialing and enrollment processes for physicians and non-physician providers. The role involves verifying credentials, handling sensitive information, and ensuring compliance with regulatory guidelines. Candidates should have a degree in Healthcare Administration and experience in managed care, along with strong organizational and communication skills.

Qualifications

• Minimum two years of experience in managed care, credentialing, or enrollment.
• Familiarity with NCQA guidelines.
• Experience in primary source verification and data management.

Responsibilities

• Complete initial and recredentialing applications for providers.
• Perform primary source verification of credentials.
• Conduct routine reviews of OIG sanctions and malpractice history.

Skills

Organizational skills

Attention to detail

Communication skills

Interpersonal skills

Education

BS in Healthcare Administration

Equivalent work experience

Tools

MS-Access

Excel

Microsoft Office

Adobe Acrobat

Job description

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Job Details

Performs necessary delegated credentialing and enrollment processes to ensure that Jefferson University Physicians, consisting of physicians and non-physician providers, and outside contracted Managed Services Organization (MSO) client physician groups and non-physician providers, are credentialed, enrolled, and remain participating with major health plans. As a team member of JUP Central Enrollments (JCE), will handle highly sensitive personal and confidential information in providing services that are critical to JUP’s revenue cycle, and also outside MSO clients. Adheres to all JUP policies and procedures as well as to NCQA guidelines and other regulatory guidelines related to health plan credentialing and enrollment.

Job Description

1. Responsible for the completion of initial and recredentialing applications for physicians and non-physician providers in accordance with JUP Delegated Credentialing procedures, NCQA guidelines, and policies and procedures of delegated contracted health plans.
2. Perform primary source verification of each physician’s credentials according to contractual requirements with delegated health plans, JUP’s policies, NCQA, and DPW guidelines. Query databases such as NPDB, ABMS, FSMB, AMA, AOA, and ECFMG for verification of credentials.
3. Contact institutions directly to verify medical training when not reported with AMA/AOA.
4. Conduct routine reviews of OIG sanctions, state disciplinary actions, and Medicaid exclusions, and track charges for verification.
5. Review physician malpractice history and prepare individual credentialing files following established standards.
6. Obtain necessary approvals and signatures, coordinate practice medical record audits, and schedule on-site practice site visit audits.
7. Summarize audit findings, present at credentialing subcommittee meetings, and document issues and resolutions.
8. Prepare agendas, record and distribute minutes, run data queries, and interpret data for reporting purposes.
9. Compile and submit lists of approved providers to health plans and report decisions as required.
10. Coordinate with health plans for audits, update credentialing systems (PECOS, CAQH, NPI), and ensure data accuracy.
11. Assist in clinical practice expansion by establishing new practice locations with health plans, collecting licensure and insurance documentation, and updating credentialing databases.
12. Maintain confidentiality, develop relationships with health plan contacts, and resolve credentialing issues efficiently.
13. Interact professionally with coworkers, visitors, and staff, adhering to core values.

Qualifications

• BS in Healthcare Administration, Finance, Business or equivalent work experience.
• Minimum two years of experience in managed care, credentialing, or enrollment, with familiarity of NCQA guidelines.
• Experience in primary source verification, query running in MS-Access, data management in Excel, and data presentation.
• Strong organizational skills, attention to detail, and ability to handle confidential information.
• Excellent communication and interpersonal skills, proficient in Microsoft Office and Adobe Acrobat.

Work Shift

Day shift (United States of America)

Additional Details

Location: 1101 Market, Philadelphia, PA. Jefferson is committed to equal opportunity employment and provides a comprehensive overview of its mission, scope, and community engagement.