Specialist, Credentialing Operations

Job Description

It’s Time for A Change...

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign’s Corporate Equality Index ; was named one of the Best Companies for Women to Advance List 2020 by Parity. org; and we publish a Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

This position is responsible for determining provider types who require credentialing, initiating Primary Source Verification Process (PSV) to begin the credentialing process for the provider. This entry level position reports to Supervisor, Credentialing Operations and/or Associate Director, Credentialing Operations.

• Responsible for full credentialing and recredentialing life cycle for partner health plan network providers
• Ensures credentialing and recredentialing files are worked timely and within established Service Level Agreements (SLAs), Operational Level Agreements (OLAs) and partner health plan contractual requirements
• Maintain an excellent working knowledge of the most recent version of National Committee for Quality Assurance (NCQA) standards and guidelines related to credentialing and recredentialing requirements
• Comply with all NCQA credentialing and recredentialing standards and guidelines
• Working knowledge of partner health plan credentialing and recredentialing policies and procedures
• Develop and maintain current desktop procedures, as requested
• Meet and maintain oversight of key performance indicators, timeliness metrics and quality thresholds
• Monitor federal and state exclusions, sanctions, and adverse events, on an ongoing basis
• Create urgency with providers and facilities via email and phone, to encourage timely and accurate document submission by establishing target dates and monitoring document submission progress
• Review practitioner and facility credentialing and recredentialing to make sure all elements are present, within NCQA, Medicaid and/or Medicare timeframes, prior to CMO clean file review and Credentials Committee review of files that do not meet clean file criteria
• Facilitate and record meeting minutes and prepare all provider profiles for Credentials Committee review and decision
• Represent Credentialing Operations department in meetings and delivering projects, as assigned
• Create, review, and publish reports and audit universe files
• Assist with generating and/or validating department reports
• Responsible for preparing documentation requested for internal and external audits, as needed
• Lead on special credentialing and recredentialing projects, as required
• Make recommendations on best practices in credentialing and recredentialing
• Obtain and track complaints, resolution times, and complaint patterns
• Perform other duties as assigned by the management team

Key Compet encies/Success Factors:

• Lives the values: Integrity, Community, Collaboration and Stewardship, as defined in the performance appraisal
• Proficient PC skills in a Microsoft Office based environment
• Excellent verbal and written communication skills
• Detail oriented with good organizational skills and ability to enter data with accuracy in a timely manner
• Ability to work collaboratively with associates and other departments
• Ability to handle multiple projects simultaneously
• Ability to adapt to fluctuating situations and perform work of a detailed nature, avoiding errors

The Experience You’ll Need (Required):

• Bachelor’s degree preferred
• Three to five years’ experience in healthcare field related to credentialing, provider enrollment and/or provider services
• Three to five years of accurate data entry and maintenance of databases, specific to credentialing, provider enrollment and/or provider services

Technical Requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.
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