Credentialing Specialist

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Benefits and Perks include:

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts with company match
• Employee Referral Bonus Program

JOB SUMMARY:

The Credentialing Specialist ensures all contracted providers meet qualifications to provide care by working closely with multiple departments and with the CVO. This position is also responsible for assisting and supporting reporting functions of provider data to appropriate agencies, committees and management.

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

• Maintain and load provider demographic information received via contracts, roster updates and/or applications to the CVO.
• Review data: correct errors detected
• Keep current on all information received; remain within departmental standards
• Extract and report data for analyses
• Help maintain database integrity and quality assurance
• Contact providers in a timely manner to obtain missing and/or incorrect documentation: follow up as necessary
• Participate on calls with network services staff to assist with troubleshooting; recommend enhancements to related programs
• Assist with the facilitation of the Credentialing Committee approval and denial notification process (i.e. welcome and denial letters)
• Complete corporate assignments as assigned
• Other duties as assigned

JOB REQUIREMENTS:

• Must be fluent in all provider types, affiliations and relationships
• Must be able to accept instructions and work independently in the completions of goals and assignments
• Proficient computer skills
• Must be self- dependable, team and goal-oriented
• Ability to accurately enter data into information system as instructed
• Ability to prioritize workload and adjust to a changing environment
• Be efficient, effective and assertive in both written and spoken communications
• Handle multiple priorities effectively
• Multi-task, meet deadlines, prioritize

QUALIFICATIONS:

• Education:

• High school diploma or equivalent required

• Post-secondary education preferred

• Experience:

• Previous experience in the healthcare field required

• Prior credentialing experience

• Prior experience with CVO platforms strongly preferred

• Prior experience in network services data management preferred

• Prior experience with Medicare Advantage plans preferred

• CMS reporting provider and data reporting experience preferred

WORKING CONDITIONS:

• Work is typically performed at home in a dedicated office space
• Typical working hours are 8:00 AM to 5:00 PM but negotiable
• Position may require flexible hours
• Travel may be required to come into corporate office if located within 40 miles.

EQUAL OPPORTUNITY EMPLOYER

Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.