Credentialing Coordinator II

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

Supports all department activities related to the credentialing and recredentialing of Medical and Behavioral Health Practitioners and Organizational Providers ("Providers"), in accordance with the Plan's policies and procedures.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities

• Independently reviews practitioner and facility credentialing files to ensure completion and accuracy of information, per Plan's policies. Ensures all files are completed in a timely manner, and meets the appropriate turnaround times
• Initiates the collection of all pertinent information/documentation from the practitioner, facility administrator or appropriate office staff. Verifies credentials through the appropriate primary sources
• Independently identifies substantive adverse issues and initiates further data collection from internal and external sources. Analyzes provider files to identify discrepancies with information. Creates thorough and complete summary profiles for Medical Director and Credentialing Committee review.
• May assists with the department's ongoing monitoring activities. Reviews appropriate reports and databases against the Plan's provider networks and completes outreach to providers regarding licensure actions.
• May review sanction and exclusion sources to ensure that providers going through initial credentialing or recredentialing are not currently debarred, suspended or otherwise excluded from participation in Medicare, Medicaid or any other federal or state health care programs.
• Assists with managing internal provider data queues (e.g. Non-pars, Terminations).
• Responsible for reviewing and researching routine expirables reports (e.g. License, Board Certification).
• Organizes and maintains assigned electronic credentialing files. Responsible for updating credentialing information within Visual Cactus and the Onyx database.
• Maintains detailed log of all pending work.
• Supports special projects and completes other duties as assigned.

Supervision Exercised:

* None

Supervision Received:

* Close supervision is received weekly.

Qualifications

Education Preferred/Desirable:

* Bachelor's degree in healthcare administration, related field, or equivalent combination of education, training and experience is required

Experience:

* 3 or more years of credentialing experience in a health plan or a hospital medical staff services department

* Certification or Conditions of Employment:

* Pre-employment background check

* Competencies, Skills, and Attributes:

* Strong oral and written communication skills

* Maintains an intermediate understanding of the National Committee for Quality Assurance (NCQA) accreditation standards, MassHealth, NH DHHS and other Federal/State credentialing requirements

* Ability to interact with other departments within the organization, and with external audiences

* Strong analytical skills

* Ability to compose accurate and comprehensive file summaries

* Accurate and detail oriented

* Flexible and able to work with minimal supervision

* Ability to manage multiple tasks and possess excellent organizational and time management skills

* A strong working knowledge of Microsoft Office products

Working Conditions and Physical Effort:

* Regular and reliable attendance is an essential function of the position

* Work is normally performed in a typical interior/office work environment

* Very limited or no physical effort required. Very limited or no exposure to physical risk

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees