Credentialing Compliance Analyst - Hybrid (Healthcare)

The Credentialing Compliance Analyst responsibilities include developing, implementing, and facilitating the regulatory and accreditation credentialing investigation process. Identifying and analyzing credentialing processes for high-risk, high-volume and problem prone credentialing processes to mitigate risk and improve provider satisfaction. Developing the scope and audit criteria based on regulatory, accreditation and business requirements. Supporting Credentialing Services by coordinating the use of the credentialing database system generating routine and ad hoc statistical reports, maintaining the quality of credentialing data, and assessing credentialing data collection tools. Reviewing potential credentialing non-compliance/discrimination cases. Developing and completing audits, compliant with legislative/regulatory requirements.

 

Responsibilities

·       Develops the Credentialing Program Description and Statement of Effectiveness and Program Descriptions for review and approval of the MCQIC, the NCQA accreditation survey and various Boards of Directors.

·       Participates in developing and maintaining desk procedures and processing guides.

·       Collaborates with internal and external resources to develop program improvements, and to reengineer processes to assure service and compliance quality.

·       Formulates recommendations based on best practices and cross-functional business operations.

·       Performs monthly reviews of regulatory and accreditation cred requirements practitioners, providers, and delegates.

·       Conducts gap analysis between requirements and corporate policies.

·       Research credentialing quality issues identified through regulatory agencies, Executive Inquiries, Consent Orders, Corporate Fraud Investigations, or other referral sources.

·       Analyzes findings and develops corrective action plans, as needed. Maintains cred databases to identify long term trends and issues in the business areas that support credentialing.

·       Fully responsible for credentialing audit program.

·       Analyzes the audit findings and identifies credentialing process problems across business areas.

·       Develop, refine, and update data tools for various audits, including tools for ad hoc audits.

·       Formulates recommendations based on best practices and cross functional business operations.

·       Analyzes and communicates the Audit Report with recommendations to the affected business areas Evaluates responses to audit findings. Reports significant audit findings to the manager when immediate action is required.

·       Develops appropriate assessment tools based on the scope of the audit and regulatory and risk management requirements since there are no industry standard tools available.

·       Verifies professional staff license for all associates; works with HR to determine status of associates.

·       Works with Management and HR for clarification concerning any data discrepancies.

·       Provides analysis, identifies trends and performs root analyses to further refine reports to identify irregularities.

·       Recommends a plan of corrective action for resolution and follows up for adverse trends identified via data analysis.

·       Ensures that routine and regular data validation monitors are performed and documented.

·       Participates on inter-departmental teams addressing credentialing process and data quality improvements.

·       Provides other support to Credentialing Department, as needed.

Education  Bachelor's Degree preferred.

Experience, Knowledge, & Skills

·       Minimum of five (5) years in a managed care setting.

·       Detailed knowledge of credentialing regulations, policy, and practices.

·       Detailed knowledge of NCQA accreditation, CMS state and federal laws and regulations, credentialing polices, and peer review process required.

·       Excellent organizational, interpersonal, analytical, presentation and written skills required.

·       Demonstrated ability to interact effectively with all levels of staff.

·       Proven ability to work independently, prioritize workflow, maintain flexibility, and work as part of the departmental team

·       Serves as a team facilitator and consultative resource for credentialing.

·       Demonstrated effective communication and analytical skills (emphasis on written skills) with the ability to work well with and associates of all levels through the family of companies.

·       Experience analyzing data and coordinating projects.

Hybrid

Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania.

 

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.