Manages all aspects of the credentialing and re-credentialing of practitioners, facilities and ancillary providers in accordance with NCQA.
Assure compliance with CMS, WV Medicaid (BMS), Department of Insurance and other regulatory entities.
Coordinates the development of annual QI reports.
Oversees the preparation of materials submitted to the Credentials Committee monthly meetings for review of practitioners/providers with variances.
Preparations and attendance of HEDIS, WV Medicaid annual audits, and CMS.
Oversees workflows for pre-delegated and annual audits of all credentialing delegated entities.
- Associates Degree or high school diploma/equivalent and four years related healthcare experience.
- Five years credentialing 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.
- Bachelors Degree.
- CPCS Certification.
- Supervisory experience.
- Experience with data systems and credentialing software systems.