What are the responsibilities and job description for the Delegated Credentialing Representative position at The Health Plan of West Virginia Inc?
Job Description
Job Description
Under the direct supervision of the Manager of Credentialing, responsible for all delegated provider credentialing activities in accordance with established THP credentialing policies and procedures that are compliant with current year NCQA credentialing and recredentialing requirements, CMS, BMS, and the states of Ohio, Pennsylvania, West Virginia as well as all bordering states.
Required :
Associates Degree or high school diploma / equivalent and two years related healthcare experience.
Strong organizational, interpersonal, and critical thinking skills.
Excellent communication skills, both written and verbal.
Ability to multi-task, prioritize workload to meet deadlines, and pay meticulous attention to detail.
Ability to troubleshoot, problem solve and work as a team as well as independently.
Experience in personal computer software applications such as Microsoft Office (Word, Excel) and Adobe Acrobat
Performs initial entry and continuous maintenance of provider record in HEART from delegated provider roster.
Assists in pre-delegated audits and annual assessment audits to ensure delegated entities compliance in The Health Plan policies and procedures as well as all regulatory / governing entities.
Assists in preparation for pre-delegated and annual assessment audits including scheduling audits and mailing pre and post audit letters; reporting audit outcomes to management.
Accurate data entry, document scanning, and navigation of provider data systems.
Basic pay class assignment / maintenance to ensure accurate claims payment.
Maintains (termination, edits, loading new information) provider records in HEART with demographic, tax ID, or other changes to ensure accuracy of information.
Excellent communication and relationship building skills.
Adheres to all policies and procedures of The Health Plan and other regulatory / governing entities as well as following standards established by NCQA, CMS, BMS, and the states of West Virginia and Ohio.
Assists with national, state, and internal audits.
Works collaboratively with the Provider Delivery Services team as well as all internal departments.
Assists with training and development of new employees related to the delegated credentialing process.
Researches and resolves internal and external inquiries regarding provider status and system set-up to ensure quality control.
Maintains confidentiality of provider information.
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