Credentialing Specialist III

Join us for an exciting career with the leading provider of supplemental benefits!

Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

In this role as Senior Credentialing Specialist, you'll play a critical role in the heart of our team, managing and overseeing credentialing activities that drive the success of our department and the company. As a key player, you will ensure that all credentialing processes adhere to the highest standards and you’ll be responsible for processing provider applications for credentialing and re-credentialing, maintaining compliance with state, federal, and NCQA guidelines, and ensuring smooth, efficient operations within the team. If you’re ready to take on a leadership role where your attention to detail, compliance knowledge, and problem-solving skills can shine, the Senior Credentialing Specialist position is your next career move. Join us in ensuring that our providers are fully credentialed and compliant, and be a part of a dynamic, mission-driven team.

In this role, you’ll be at the forefront of ensuring our providers meet the rigorous standards needed to deliver quality care and be the gatekeeper for ensuring our healthcare partners meet regulatory requirements and industry best practices, directly impacting the quality of care delivered to patients. You’ll work closely with cross-functional teams to ensure seamless operations, minimize risk, provider data is accurate, up-to-date, and compliant and help uphold the integrity of our credentialing processes.  Your work helps shape a trusted network of healthcare providers, ensuring patients receive care from credentialed and qualified professionals.  Whether you're guiding the team through regulatory changes or improving efficiencies, your expertise will directly impact the success of the organization and the quality of service we provide to our clients.

Competencies:

Functional:

• Perform all aspects of the investigation and management of provider credentialing and assignment of related processes to ensure compliance.
• Research questions and problems regarding federal/state regulations and industry standards.
• Participate in ongoing monitoring and competency of our providers.
• Contribute to on-going process improvement.
• Manage and maintain positive engagement with CVO.
• Receives and process incoming applications and supporting credentials from providers.
• Performs timely follow-up with providers on all pending applications.
• Performs the primary source verification according to departmental policies and NCQA standards when not completed by CVO.
• Builds and accurately maintains provider information in various systems.
• Performs Quality Assurance of all provider credentialing information in preparation for committee(s).
• Responds to inquiries regarding the status of provider’s application.
• Utilizes organizational templates to communicate with providers about the status of their application with the organization.
• Provides support to Credentialing Specialist I on functional responsibilities.

Core:

• 3 + years of Working knowledge of NCQA standards and payer credentialing standards.
• Knowledge of PSV, CAQH, OIG, NPDB
• Knowledge of vision, dental or hearing industry.
• Strong computer, data entry and clerical skills.

Behavioral:

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth. 
• Initiative: readiness to lead or take action to achieve goals.
• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.
• Flexible and responsive:  managing new demands, changes, and situations.
• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
• Integrity & responsibility:  acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• Bachelor's degree or equivalent education and experience.
• Intermediate use of Microsoft Excel; ability to create and utilize pivot tables, sorting, filtering etc.
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 25 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• CPCS certified
• 5+ years credentialing experience, preferably in a managed care setting.

FLSA Status: Hourly/Non-Exempt

Salary Range: $18.33 - $28.67 per hour.

How To Stay Safe:

Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avēsis, We See You.  We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic.  At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients.  We focus on recruiting, training and retaining those individuals that share similar goals.  Come Dare to be Different at Avēsis, where We See You!

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