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Job Summary

Under Supervision, This Position Responsible For Review And Completion Of Primary Source Verification Data In An Accurate And Timely Fashion For Credentialing And Recredentialing Of Practitioners For Multi States. Conducting Research In Order To Complete The Application File. Processing Practitioner Application In Accordance With Company, State And Product Requirements For Assigned Files. Respond To Practitioner Office Representatives Or Internal Department Staff Regarding Status Of The Application And / Or Supporting Documentation.

1. Audit, monitor and/or report defined elements needed to perform defined credentialing and recredentialing activities according to applicable regulatory agencies and HCSC internal credentialing policies and procedures.
2. Ensure specific provider data required for the Credentialing Provider Committee to review and render a decision on network participation for professional providers is accurate. Ensure Professional Providers applying for initial or ongoing network participation Managed Care/Government products are credentialed or recredentialed timely and appropriately for presentation to the Medical Director Professional Provider Credentialing Committee following the NCQA/URAC/CMS and state regulations, guidelines and standards.
3. Work with Network Management to collect deficient data or the direct collection of required data elements identified as a customer service issue; timely preparation is defined as submission of the provider-credentialing file within specified days of being keyed into the system and completion of the recredentialing file prior to the assigned target date, which follows the NCQA, URAC, CMS and/or state regulations and guidelines.
4. Query working databases to verify status of practitioner applications.
5. Verify and ensure the accuracy of information entered from the network practitioner application and/or re-credentialing packet into the Credentialing and Provider Data Systems. Ensure information in the system reflects the practitioner files in support of the MCO and Compliance Policies and standards.
6. Monitors the applications returned from the provider in order to ensure that required information has been submitted and applications are processed timely. If application is incomplete, return to the Network Management or provider with the Incomplete Notice detailing the information that is missing/deficient. Track receipt and return dates of audited applications in the Credentialing system.
7. Maintain a good working knowledge and understanding of all Corporate, Compliance, and departmental policies, procedures, and regulations related to the credentialing verification process that includes the understanding the laws of each state and the NCQAURAC/CMS guidelines and standards.
8. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
9. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
10. Maintain complete confidentiality of company business.
11. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS: * High school diploma or GED. * 2 years business experience. A combination of college level education and experience will be considered * Clear and concise interpersonal, verbal and written communication skills. * Organization skills to handle multi-processes and multi-states. * PC experience in Windows, Word, Excel, Access, and other business related/associated databases.

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HCSC Employment Statement:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.