Resp & Qualifications
Purpose: The incumbent will report to a Manager within the Operations Technical Support, Compliance & Quality department. The incumbent(s) will perform their role in support of the Provider Information & Credentialing (PI&C) department in performing in-depth system and procedural audits of credentialing, re-credentialing, demographic updates, non-par provider loads and incoming provider telephone calls to ensure that all credentialing activities are executed in accordance with CareFirst credentialing criteria and the regulations set forth by Federal Regulations, the state of Maryland, District of Columbia, the state of Virginia and NCQA standards. The incumbent is considered a Subject Matter Expert (SME) and is responsible for knowing business rules governing the credentialing, re-credentialing and demographic updates of physicians/providers participating in the BCBSMD, HMO/MPOS, RPN, PPO/PPN networks and Medical Panels.
The incumbent provides a comprehensive analysis of transaction, systems and procedures while also providing coaching and mentoring to all levels of associates. The Quality Assurance Auditor will also assist in the development and management of processes to deliver, evaluate and continuously improve all areas of Provider Information & Credentialing. The incumbent must be able to perform the Provider Credentialing & Network Analyst I, II, III roles and is the “go-to” expert when a credentialing case must be resolved to enable downstream claims to enable completion of credentialing process.
The incumbent’s responsibilities include, but are not limited to:
1. Core Auditing Processes
Performs audits of completed credentialing, re-credentialing, demographic updates, non-par provider loads and incoming provider telephone calls completed by the Credentialing Analysts and Network Support Analysts to ensure that the information entered into Portico, the enterprise-wide provider file system and the Provider Information Control System (PICS) is loaded accurately with the correct provider file information, such as, NPI number (National Practitioner Indicator), Tax Identification Number, rate sheet codes and other pertinent credentialing data elements and are consistent with system requirements supporting NASCO, Facets and FEP so that claims are processed correctly on the claims processing platforms. The QA Auditor provides technical support, detailed audit results and analysis of error trends with the ultimate goal of improving the associate performance and accuracy. Provides coaching and mentoring to associates on a daily and monthly basis. The QA Auditor will perform all necessary follow-up activities related to audit errors to ensure that corrective action have been appropriately taken. The Auditor also ensures that the information displays accurately on both the CareFirst.com website and the provider directories. Routinely monitors incoming telephone credentialing inquiries handled by the telephone support unit to ensure information accuracy and enhance provider satisfaction. Reviews non-par provider loads to ensure that the non-par provider information is loaded in accordance with CareFirst guidelines. Creates the daily inventory dashboard and submits to Management. Adheres to all departmental quality standards.
2. Coaching and Knowledge Expert
Serves as a subject matter expert and coach for the Credentialing Analysts, Networks Support Analysts, Credentialing Phone Unit and Non-Par Credentialing Analysts. Is considered a go-to resource in Provider Information & Credentialing and technical transactions for Facets, NASCO, FEP and PCMH Medical Panels. This includes face-to-face or telephonic error review/feedback sessions with those audited as well as chair side auditing of live transactions as needed. Acts as the systems expert to resolve or correct provider/practitioner records that do not update properly in downstream legacy systems. Provides regular and constructive feedback on an individual or group basis to Credentialing Analysts. Conducts training & mentoring of new auditors and credentialing associates. Performs additional duties as required including participation on projects and workgroups, including CareFirst management (PI&C Director, Managers and Supervisors). Also conducts internal consistency checks ensuring uniform and fair auditing practices throughout the department, across all lines of business. Reviews and analyzes error trends to provide reporting to improve results.
Serves as a subject matter expert for all previously mentioned to the department by providing technical expertise regarding any system errors and customer service procedures. Conducts and participates in refresher training within the Provider Information & Credentialing department. PI&C Auditor has the goal of learning the Senior Auditor’s accountabilities.
3. Audit Process Creation and Enhancement
Identifies procedural, system and training issues based upon audit findings and initiates resolution to these problems through recommending alternate procedures/processes and developing and evaluating SOPs. Works closely with the department Trainer, Supervisors and Business Analyst to evaluate the effectiveness of current processes/procedures, techniques, systems and associates. Participates in training & mentoring of operational associates.
4. Credentialing Advisory Committee and Projects
Prepares credentialing and re-credentialing files for review by the CAC (Credentialing Advisory Committee) on a weekly basis. Performs additional duties as required including system testing, new system implementation and workgroups, etc. in accordance with corporate and department guidelines provide audit support as required.
Distribution of Accountabilities:
• Must have 2-4 years’ experience in at least one of the following: health care delivery, health insurance, claims and service or related fields; and at least 1 year additional experience in either credentialing or auditing.
• Must work with minimal supervision in a fast paced environment.
• May be needed to work overtime on weekends and weekdays.
• Working knowledge of Microsoft Windows and Office applications.
• Proven judgment and decision making ability; must be able to make and carry out broad range of decisions while remaining consistent with the company and regulatory guidelines
• Ability to represent the department persuasively and articulately in meeting with other departments, and external clients and partners
• Effective written and oral communication skill
• Effective coaching and training/Excellent Interpersonal skills
• Ability to give effective feedback
• Excellent planning, research and organizational skills
• Strong analytical ability, planning and problem skills
• Intermediate to Advanced PC knowledge or web based applications
• Has proven skills in coaching and motivating associates. Must work with minimal supervision in a fast paced environment.
• Contributory participation in workgroups and/or projects
• The ability to manage multiple priorities simultaneously; project management
• Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Bachelor’s Degree preferred in Business or Health Care related fields.
• Working knowledge of Portico and FACETS systems. Understanding of the PCMH program and needed data structure. Other systems utilized: TRMS, Access, CareFirst Document Writer and Pega
• Health insurance benefit, product, medical and system knowledge/experience.
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 4.13.21
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship