Virginia Premier Health Plan, Inc.

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Credentialing Team Lead

Credentialing Team Lead

Job Locations 
US-VA-Glen Allen
Job ID 
2017-4047

Job Description

Overview

The Credentialing Specialist –Team Lead position, in the Medical Management Department, will be responsible for all credentialing and quality related activities to include, but not limited to, credentialing efforts associated with or required by NCQA, DMAS, CMS, and/or any other regulatory guidelines. The incumbent will also be responsible for assisting the manager, serving as a team lead with credentialing operations, queries and reporting.

Responsibilities

  • Responsibilities include primary source verification of each provider’s medical license, DEA, education and training, board certification, medical malpractice insurance and history,     Medicare/Medicaid sanctions, hospital privileges and all other activities applicable to the completion of the provider file
  • Responsible for loading and managing accurate data in the credentialing database(s) and preparing reports and other documents to be presented to the Medical Management Committee and/or Credentialing Committee, routinely updating providers on their credentialing status and as requested and providing timely follow-up for requests of outstanding information
  • Responsible for providing administrative support for the processes and activities of the credentialing department. This includes, but is not limited to, copying, filing, and obtaining required credentialing documents
  • Ability to assist the manager with monitoring the accuracy of data manually entered (by staff) or electronically uploaded into the Credentialing Database, work flow adherence and project completion, as needed
  • Schedule, follow up on and/or complete all requirements for Delegated Entities to include data collection/entry/reconciliation, yearly audits, and process/policy reviews when necessary
  • Assist the manager with leading special projects that involve the credentialing functional area
  • Assist the manager with writing policies and procedures, as well as monitoring compliance with those policies in addition to internal standard operating procedures
  • Assist the manager with operational reporting, operational database needs, the implementation of new technology within the credentialing area, and assuring ongoing data integrity
  • Prepare all required documentation needed for presentation to the Credentialing Committee
  • Work collaboratively with other departments
  • Lead, research, resolve, and present special projects
  • Attend seminars, conferences, and/or meetings in the Manager’s absence
  • Facilitate staff meetings in the absence of the Manager
  • Problem shoot with credentialing related programs, application, and technology
  • Assist the manager with internal quality file reviews prior to each Credentialing
  • Committee meetings to assure completeness, accuracy and timeliness.
  • Other duties as assigned
  •  

Qualifications

MINIMUM EDUCATION REQUIREMENTS:

  • Associate or Bachelor’s Degree Highly Preferred

SPECIAL KNOWLEDGE AND/OR SKILLS:

  • Ability to communicate effectively, both written and verbal, with technical, clinical and business owners at the Plan and Corporate level
  • Demonstrated ability to lead and/or provide guidance to others
  • Experience in Credentialing Database systems
  • Strong computer skills with extensive expertise in data base systems, Excel, and
  • Microsoft Word
  • Exceptional interpersonal and problem solving skills

WORK BACKGROUND/EXPERIENCE:

  • Two or more years relevant experience
  • Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred
  • Experience or exposure to NCQA Credentialing standards

PHYSICAL REQUIREMENTS

Physical health sufficient to meet the ergonomic standards and demands of the position.

 

ABOUT US

 

Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

Our mission is to inspire healthy living within the communities we serve!

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