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Assistant Manager

Jersey Mike's

42 Boston Post Rd. West, Marlborough, MA 01752-1827

    credentialing specialist

    Health One Alliance, LLC
    Dalton, GA 30720
    Full-time, Part-time
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    Job Description


    Job Purpose

    The Credentialing Specialist is responsible for the credentialing and recredentialing of providers in compliance with NCQA, CMS, DOI, state credentialing standards and HealthOne Alliance policies and procedures. This includes entering data, performing appropriate credentialing verifications, preparing and presenting at Credentialing Committee Meetings, preparing for Board of Directors reviews and notification of the completed credentialing process. The Credentialing Specialist will assist in conducting Credentialing Delegation Reviews as well as preparation and delivery of monthly and quarterly reporting for various Delegated Entities. This role will assist in the monitoring of license expirations and status changes and take action when appropriate. The position also helps to review and update criteria and credentialing policies and procedures, as necessary, but no less than annually.


    Duties and Responsibilities

    • Works directly with providers to ensure all necessary credentialing information has been received prior to beginning the credentialing process
    • Enters provider data into appropriate data management systems
    • Performs all credentialing verifications necessary to complete the credentialing process while maintaining the appropriate compliance standards in an electronic format
    • Prepares and presents providers records for Credentialing Committee Review
    • Prepares Credentialing Committee recommendations for Board of Directors review
    • Notifies providers of credentialing decisions within compliance timeframes
    • Assists providers with all questions related to provider credentialing
    • Performs provider re-credentialing, at least every 36 months in compliance with NCQA standards
    • Assists with ensuring providers are compliant with the NCQA, CMS, DOI and state requirements regarding availability and standards and evaluates the standards to ensure they address the requirements outlined by NCQA, CMS, DOI and state
    • Assists with Credentialing Delegation Reviews by presenting credentialing files to various Delegated Entities and/or reviewing credentialing files, policies and procedures and other monitoring reports to ensure compliance of various Delegated Entities
    • Assists in preparing and delivering monthly and quarterly reports to various Delegated Entities
    • Assists in monitoring of license expirations and status changes in LEMM and takes action when appropriate
    • Assists in reviewing and updating criteria and credentialing policies and procedures, as necessary, but at least annually
    • Educates providers regarding criteria and credentialing policies and procedures when necessary
    • Works with Network Management to ensure providers' initial information and updates are sent for processing timely and accurately
    • Assists Network Management and Provider Relations with changing a provider from direct relationship to delegated relationship
    • Maintains provider and patient confidentiality at all times
    • Provides positive, supportive, communication to providers at all times
    • Collaborates with other departments and outside agencies to meet identified needs of the providers and their patients, while also ensuring credentialing staff cooperation
    • Assesses environments for safety hazards which could harm patients, visitors, or other provider employees and reports hazards to appropriate supervisors
    • Regular and predictable attendance
    • Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
    • Maintains work area in a clean and orderly condition and ensures safe operating conditions within area of responsibility
    • Works to encourage and promote Company culture throughout the organization
    • Other duties as may be assigned


    • Bachelor's Degree in Health Care Administration, Nursing, Business or related field preferred; or equivalent work experience
    • Broad-based business experience within the healthcare/managed care environment


    • Ethics - Honest, accountable, maintains confidentiality
    • Reliability - The extent to which the employee can be depended upon to be available for work, do it properly, and complete it on time. The degree to which the employee is reliable, trustworthy, and persistent.
    • Sense of Urgency - Meets deadlines, establishes appropriate priority, gets the job done in a timely manner
    • Problem Solving & Decision Making - Displays ability to define a problem, develops workable and realistic alternatives, and selects appropriate alternative to resolve problem. Decisions made are generally correct, and the time taken to make such decisions is reasonable.
    • Organization Skills - Information organized and accessible, maintains efficient workspace, manages time well
    • Communication Skills - Possesses effective communication skills: oral, written, listening
    • Conflict Management - Good listener, committed to finding solution to problems, works well with difficult people
    • Interpersonal Skills - Builds strong relationships, is flexible/adaptable, works well with others, solicits feedback
    • Job Knowledge - Knowledge of products, policies and procedures; OR knowledge of techniques, skills, equipment, procedures, and materials
    • Planning & Organizing - Displays ability to effectively plan, organize and implement applicable tasks or projects in relation to established goals and objectives

    Physical, Mental, Environmental & Working Conditions

    Moderate amount of walking, sitting, and writing. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day events in the execution of job duties. Need for flexibility and adaptability to change. Candidate must be self-disciplined and a self-starter and able to work independently with a flexible work schedule.



    Posting ID: 597160909Posted: 2021-01-14