Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

Under direction of the Credentialing Supervisor, the Credentialing Associate is responsible for obtaining credentialing related information for all new THP affiliated physicians and allied providers to facilitate the credentialing process. The Credentialing Associate may process less complex recredentialing files in accordance with THP's policies and procedures, state laws and/or regulatory requirements (e.g. NCQA). In addition the Credentialing Associate supports all incoming work to the department to assist in preparing files for processing, obtaining missing information and to support the department as needed.

Job Description

• Essential functions occur simultaneously, therefore, the employee must be able to appropriately handle each essential function, prioritize them, and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment. Requires the ability to learn and apply TAHP policies consistently and seek out guidance when necessary. The Credentialing Associate is conversant in credentialing policies and procedures, works independently and is a resource to the team.


• Responsible for obtaining and maintaining data related to credentialing of physician and allied provider credentialing information for new and established health plan practitioners in accordance with THP's policies and procedures, state laws and regulatory agencies, including but not limited to:
  
  
  • Assessment of adequate and accurate information for participation in THP, including a limited knowledge of provider contract information;
  
  
  • Accurate and timely entry of initial and existing credentialing applications into the credentialing information system (Cactus);
  
  
  • Obtain information related to licenses, board certification, etc;
  
  
  • Assist with the intake of initial and recredentialing applications to the department;
  
  
  • Manage independent contract requests as directed by the contracting area;
  
  
  • Retrieval of missing and/or expired information/documentation required for credentialing;
  
  
  • Act as resource for calls from providers with questions relating to the credentialing process;
  
  
  • Assist as needed in tasks supporting the department such as file room or other departmental requests;
  
  
  • Identify for the Credentialing Supervisor those issues of broader complexity or sensitivity that may require further action.
  
  
  • Assist with preparation for the Quality of Care Committee meetings.
  
  
  • Assist with Meets Criteria reports and other support functions for Credentialing.
  
  
  • Participate in task forces and/or other meetings as assigned and execute other responsibilities as assigned.
  
  
  
  

Requirements

• COMPLEXITY

All information (written, verbal, electronic, etc.) Ability to appropriately identify emergency situations and follow the appropriate protocol. Must have the ability to maintain and manipulate a complex credentialing information system. Must be able to prioritize multiple tasks and achieve deadlines. Must have ability to adapt to changing environment. Strong written and verbal skills are necessary. Individual must possess initiative, judgement, exceptional organizational skills and keen attention to detail. Must be able to work and process time-sensitive information.

• PERSONAL CONTACTS

Must be able to work cooperatively as a team member. Frequent written and verbal contact with physicians, office staff and internal customers. Must use discretion when dealing with Plan providers and all other departments.

• CONFIDENTIAL DATA

All information (written, verbal, electronic, etc.) that an employee encounters while working at TAHP is considered confidential. Requires confidentiality with regard to provider information and credentialing documents.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime)

• Fast paced office environment handling multiple demands. Must be able to exercise appropriate judgment as necessary.


• Requires the ability to use PC. Ability to transfer information from paper-form to on-line data is necessary. In the absence of specific direction, must be able to prioritize workload. Work requires ability to use independent judgment and discretion in decision-making which may impact the organization.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

As of Nov. 1, 2021, full vaccination against COVID-19 is required to enter any Point32Health office or if, on behalf of Point32Health, you are meeting in-person with individuals outside of a Point32Health office. As of Dec. 8, 2021, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

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