WHO WE ARE:
GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.
WHO YOU ARE:
The Credentialing Coordinator is responsible for coordinating and maintaining the provider credentialing and recredentialing process to ensure compliance with CMS Medicare Advantage requirements, applicable state and federal regulations, contractual obligations and organizational policies. This role verified provider qualifications, maintains accurate credentialing records, supports timely provider onboarding and collaborates with departments and delegated entities to ensure operational efficiency and regulatory compliance.
ESSENTIAL JOB FUNCTIONS:
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Processes applications and credentialing files, checking for completeness and accuracy.
- Obtains primary source verification of competencies relating to the applicant such as relevant board certifications, health facilities affiliations, licensure, certifications, DEA, OBNDD certificates, and malpractice coverage following GlobalHealth Policy and Procedures including NCQA requirements.
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Queries and processes primary source verification and accreditation information including NPDB, OIG, SAM, Revoked Medicare Providers & Suppliers and Medicare Opt Out.
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Emails or faxes GlobalHealth Provider Data Forms or UCA applications for initial credentialing and reappointment when requested.
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Downloads provider application and all available primary source verified documents from CAQH
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Prepares credentialing files and submits practitioner and provider information to Credentialing Committee for approval in timely manner.
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Continuously maintains and updates accurate credentialing files and database for both practitioners and providers. Maintains communication with appropriate practitioners to ensure records are up-to-date and consistent.
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Assists Supervisor of Credentialing, and other leaders and Executive Credentialing Committee to ensure that proper credentialing procedures are followed.
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Notifies practitioners and providers of Credentialing Committee decisions and renewal dates and responds to request for status of credentialing.
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Manages, requests and follows up expirable as needed (license, COI, Board Certifications, etc.).
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Saves approved documentation, files to the credentialing drive, and keeps all appropriate records in provider folders.
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Maintains confidentiality of all credentialing files.
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Completes various work assignments as requested by supervisor in a timely manner.
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Maintains current desk procedures and reference materials.
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Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
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Performs other duties as assigned.
EDUCATION AND EXPERIENCE:
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High School diploma or equivalent required
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Three to five years of credentialing experience
KNOWLEDGE, SKILLS AND ABILITIES:
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Working knowledge of credentialing process and guidelines
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Knowledge of primary source verification and sources to obtain
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Proficient in computer and applications including Word, Excel, Credentialing Database, Outlook, HAX and other applications as required
- Knowledge of credentialing forms and required documentation for application processing
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Knowledge of CMS, OSDH, and other accrediting agency standards
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Strong data entry skills with high degree of accuracy
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Excellent customer service skills and telephone etiquette
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Must be able to communicate successfully
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Knowledge of types of modalities, specialties, and education required for each practitioner and provider
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Ability to maintain accurate database and documentation
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Proper organizational/time management skills
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Exercises judgment when dealing with applicants by demonstrating the ability to analyze
situations and use tact and diplomacy to arrive at resolutions
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Strong verbal, written and organizational skills, must be self-directed/self-motivated and must have analytical, problem-solving and decision-making abilities
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Ability to learn and retain new skills quickly while maintaining a high level of accuracy.
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Must have the following mental abilities: Alertness, precision, analytic ability, problem solving, memory, communication, creativity, concentration, judgment, imagination, initiative and persistence to complete roles and responsibilities.
- Must have a helpful, collaborative attitude and a willingness to learn and support overall operations of the department
WORK ENVIRONMENT:
Current work environment is remote, however, some state exclusions apply.
Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.
TRAVEL:
Some external travel is required and would therefore expose this employee to average traffic hazards.
SUPERVISORY RESPONSIBILITY:
This position is not a supervisory position.
OTHER DUTIES:
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
