Parkland Community Health Plan’s (PCHP’s) Credentialing Analyst supports the credentialing program that implements federal, state, and local regulatory and NCQA accreditation requirements. Ensures that all practitioners and facilities are evaluated upon entry into the PCHP network and conducts an ongoing review of the providers. Gathers, analyzes, and report provider data for the provider directory, billing needs, and member support. Communicates with providers and provider groups to answer their questions and concerns or direct to the proper department. Assists with oversight audits of delegated and non-delegated providers.
Bachelor’s degree is required.
3 years of managed care or credentialing experience.
Experience with CAQH, Texas Association of Health Plans (TAHP), NCQA accreditation, Aperture, or National Provider Data Bank (NPDB) is preferred.
Experience with federal, state and/or local managed care statutes is preferred.
Experience with managing provider data is preferred.
Equivalent Education and/or Experience
May have an equivalent combination of education and experience to substitute for the education requirements.
National Association Medical Staff Services (NAMSS) certification is preferred.
Skills or Special Abilities
Advanced proficiency in Microsoft Excel to include VLOOKUP, creating complex function and equations.
Proficiency in Adobe Pro and Microsoft Outlook.
Experience using SharePoint is preferred.
Strong interpersonal, problem solving and relationship building skills with positive attitude and demeanor.
Ability to take initiative to research and form conclusions independently.
Ability to manage multiple deadlines and time constraints in a fast-paced environment.
Demonstrated ability to collaborate effectively and work as part of a team including internal and external stakeholders.
Ability to perform detail work efficiently and with a high degree of accuracy.
Clear and professional verbal and written communication skills with the ability to clearly explain complex processes.
Skilled in interpreting, analyzing, and providing recommendations regarding data accuracy and data collection needs and processes.
Excellent planning, organization, time management, and documentation skills.
Builds and maintains relationships with external vendors and credentialing partners including Aperture & Texas Association of Health Plans
Administrates reports in external database portals & analyze data, confirm accuracy, and present to internal department.
Assists with the oversight of the delegated and non-delegated provider and facility’s data.
Gathers, analyzes, and reports provider data to internal and external customers.
Ensures that all practitioners and facilities are evaluated upon entry into the PCHP network and conducts an ongoing review of the providers.
Identifies opportunities for improvement through the audit process and provide recommendations.
Accurately tracks, reports, and follows up on the status of credentialing applications.
Maintains a strict degree of confidentiality in all areas relating to provider credentials, status, and provider personal information.
Familiar with state specific all credentialing department policies and procedures.
Assist with miscellaneous audits projects throughout the year as required.
Communicates with Credentialing Manager regarding any or all credentialing delays or issues.
Other duties as assigned.
Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
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