Credentialing Analyst - FL MCD

Aetna - Sunrise, FL (30+ days ago)3.8

Full-timeEstimated: $38,000 - $51,000 a year

Manages provider/producer requests for participation. Assess Credentialing Management Data (Business Review, Initial/Recredentialing/Off-cycle and ongoing license/sanction monitoring) for all network and non-network providers/producers. Ensures all provider/producer information is verified and accurately recorded/maintained facilitating member access, protection against substandard care and minimizing corporate risk. Develops and maintains standards/processes for credentialing data ensuring database integrity; compliance with legislative, regulatory and accrediting body requirements; and manages communication with other departments regarding credentialing processes and database improvements.. Reviews, analyzes, evaluates, validates provider/producer information against business/credentialing requirements and maintains information in Credentialing data bases. Supports extensive research and analysis of sensitive provider/ producer issues; addresses data integrity issues.

Fundamental Components:
Develops, motivates, evaluates and coaches staff on work procedures, proper call handling and teamwork delivering excellent customer service. Is visible and available to staff to answers questions, monitor calls and give ongoing feedback.
Maintains high production and quality factors.
Participates in development of credentialing processes and workflows. Identifies improvement opportunities and recommends enhancements and workable solutions.
Provides telephonic education to providers/producers on credentialing policies and procedures. Identifies and communicates trends (quality of results, efficiencies of processes).
Researches and prepares risk sensitive or complex business review/credentialing verification items for CPC.
Reviews completed investigative files of co-workers for completion and accuracy. Manages vendor on-line access of primary verification sources.
Provides ongoing support to department members in completing research and analysis to resolve complex issued raised by providers/producers and other internal/external customers.
Directly contacts providers/producers and/or outside entities to clarify data quality issues.
Provides issue resolution for providers/producers, during the credentialing or data management processes.
Responds to network or provider/producer inquiries, including contracting and credentialing policy, procedures, credentialing status. Perform data entry and systems maintenance as needed; align data across systems.
Ongoing License Sanction monitoring and reporting to minimize corporate risk.

Background/Experience Desired: Track record of prioritizing work, multi-tasking, and managing workload efficiently. Demonstrated Proficiency with MS Office Suite Applications and strong keyboard navigation skills are required. Education and Certification Requirements High School Diploma or G.E.D. College degree or equivalent work experience preferred. Additional Information: Possesses a working knowledge of Business Review/Credentialing processes, EPDB, EPC and CARDS. Ability to consistently meet and/or exceed performance/production goals.

The highest level of education desired for candidates in this position is a High School diploma, G.E.D. or equivalent experience.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.