Purpose: This role will credential practitioners for network participation with PPHP and accurately maintain all provider data within SF to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards. Essential Functions: 35% Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the PPHP networks. Once verified, accepted and approved, determines the appropriate networks and notifies provider. 20% Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, and provider file updates. Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved. Professional etiquette, communications and sound decision making is required. 20% Maintains the provider file, the Salesforce (SF) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities. 10% Responsible for identifying, analyzing and resolving immediate and existing provider file issues. Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered into the provider file database, ensuring a successful integration with the other corporate systems. 10% Audits all delegated entities on an annual basis to ensure compliance with CMS and NQA standards. 5% Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education Level: High School Diploma Experience: 3 years health insurance/managed care credentialing operations experience. 2 years of Delegated Credentialing Auditing. Preferred Qualifications: Bachelor’s Degree in Business, Healthcare Administration or related field Knowledge, Skills and Abilities (KSAs) Proficient: Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables. Proficient: Excellent verbal and written communication and interpersonal skills. Ability to develop and