SUMMARY:
The primary responsibility of this position is the verification and assessment of providers’ qualifications to render patient care services. The Credentialing Coordinator creates and maintains credentialing files; determines whether providers meet established corporate, state, and national standards; prepares and presents credentialing information for review by the Credentialing Committee and/or designated clinician consultants; and documents and communicates credentialing approval decisions. This position is responsible for answering inquiries related to The Alliance’s credentialing program.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Provider Credentialing Program Administration: This position fields and resolves questions and concerns from network providers or internal staff regarding the credentialing process or the credentials of participating providers. This position enters provider demographic, practice, and credentialing data in the appropriate databases and performs outreach to providers as necessary to obtain required information. The individual performs primary source verification of provider credentials and/or coordinates with vendors as needed to ensure that initial credentialing and recredentialing is timely and completed in accordance with National Commission for Quality Assurance (NCQA) standards. This role identifies, investigates, and validates discrepancies and adverse information related to providers’ credentials, professional conduct, or competence. The individual performs ongoing monitoring and investigation of professional sanctions, member complaints, and quality of care concerns regarding participating providers.
- Credentialing Committee Support: This position will prepare and present completed credentialing files for review by the Credentialing Committee, Medical Director, and/or other designated clinician consultants. The individual may recommend appropriate action based on the circumstances of a provider’s professional practice, applicable regulatory requirements, and credentialing program policies. This position is responsible for documenting and communicating credentialing findings and decisions with appropriate poise, tact, and diplomacy, while protecting the confidentiality of sensitive provider information as required by state and federal law.
- Coordination with Provider Operations Staff: This position is responsible for working collaboratively with Provider Operations staff to enter and maintain accurate provider records in the processing system. This position will assist Provider Operations staff in responding to provider inquiries, collecting information, and preparing provider communications.
Other Projects and Duties: This position may assist with external inquiries as guided by contractors or provider operations staff. This position recommends process and system enhancements to improve the efficiency and accuracy of credentialing activities and further the mission of patient safety. This position may serve as back up to the Manager of Credentialing and Provider Operations for relevant business needs including but not limited to report generation, orientation and training of new staff, updating process documentation and correspondence templates, and providing subject matter expertise to other operational areas and/or cross-functional workgroups.
QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: Education equivalent to a four-year high school education and advanced coursework in word processing and business. Two-year associate degree in business, communication, legal studies, healthcare administration, or a related field preferred. At least two years of experience in provider credentialing in a hospital, health system, or managed care environment required.
Language Skills: Strong written and verbal communication skills, including active listening and the ability to pose appropriate questions. Ability to read, analyze, and interpret general business correspondence, contracts, regulations, and other legal documents. Ability to write reports, service descriptions, and business correspondence. Ability to effectively present information and respond to questions from internal and external groups.
Mathematical Skills: Ability to calculate and apply figures and amounts such as discounts, interest, ratios, and percentages to practical situations.
Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations that go beyond clear, concise guidelines. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to organize assignments, plan tasks, monitor progress, and achieve established goals while adapting to critical business needs.
Other Skills and Abilities: A solid background in using personal computers is essential and must include knowledge and experience in Microsoft Word, Microsoft Excel, and database software.
Certificates, Licenses, Registrations: None
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit. The employee is frequently required to talk or hear. Specific vision abilities required by this job include close vision and ability to adjust focus.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level of the environment is generally low to moderate.
The Organization
As a not-for-profit cooperative, The Alliance is employer-owned and remains a trusted, objective partner for employers and their brokers who seek improved access to high-value healthcare.
We’re Madison-based, but we work with 340+ employers across the Midwest and contract with over 38,000 doctors and other healthcare providers in the region. Our goal is to help employers better manage their healthcare costs while remaining transparent and emphasizing value – creating healthier, more engaged workforces.
The Alliance is celebrating over 30 years as a mission-driven and member-focused collective with experienced leadership and strong organizational departments backed by top talent. By joining The Alliance, you’ll become part of a passionate, collaborative, and supportive organization: one that fosters meaningful connections and relationships with high levels of employee engagement and satisfaction.
Our health plan is self-funded, which means we share the same interests and use the same tools that we offer our clients. We lead by example because when we take care of our employees, they take care of our clients (and their employees).
Our DEI Commitment
Diversity, Equity, and Inclusion (DEI) are critical for The Alliance to realize Our Vision and attract, retain, and excite exceptional people. The Alliance is committed to embedding DEI into our culture such that diverse experience and perspectives are valued and welcomed, driving innovative solutions for our employer members, employees, and their families.
