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Senior Credentialing Specialist

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
Manage provider requests for participation. Assess Credentialing Management Data (Business Review, Initial /Recredentialing/Off-cycle and ongoing license/sanction monitoring) for all network and non-network providers. Ensure all provider information is verified and accurately recorded/maintained facilitating member access, protection against substandard care and minimizing corporate risk. Develop and maintain standards/processes for credentialing data ensuring database integrity; compliance with legislative, regulatory and accrediting body requirements; manage communication with other departments regarding credentialing processes and database improvements. Lead team projects to standardize and optimize processes. Participate as credentialing subject matter expert in health plan implementations and expansions. Acts as health plan support and liaison by conducting training, addressing issues, monitoring performance and ensuring state contractual requirements are met.

Fundamental Components:
  • Maintains highest performance of Credentialing Analyst functions
  • Provides education and training to providers/producers and/or internal customers on credentialing policy and procedures
  • Works collaboratively with network staff (local and regional) in issue/problem identification and resolution
  • Conducts ongoing process audit to evaluate compliance with standards and outcomes (e.g. quality, accuracy, timeliness)
  • Audits timeliness and maintains resource material and/or library of available resources such as standard operating procedures, contractual references, state license sources, etc.
  • Provides coaching/mentoring to peers and co-workers
  • Assists with training to staff members and health plans
  • Coordinate with Learning and Performance team for training
  • Attend cross functional meetings
  • Assign team leads and attend all team lead meetings
  • Creates and manages action plans for assigned projects relative to special network initiatives, workflow or quality improvements
  • Maintain work plans
  • Assigned to Health Plans as team lead
  • Completes all credentialing requirement documents; identified by contract requirements; managed by compliance
  • Provides deliverables for credentialing
  • Apply state readiness review deliverables
  • Implement risk/issue reporting
  • Implement policies, applications, forms, letters, and desktops/standard operating procedures
  • Manage day-to-day desktop/ standard operating procedures revisions
  • Oversee Credentials Verification Organization readiness
  • Establish and support Medicaid committee functions
  • Complete outreach for document/data collection
  • Meet state, NCQA, and CMS requirements
  • Familiarize with leadership reporting requirements
  • Coordinates receipt of provider/producer data with outside vendors and other entities
  • Meet all turn-around time commitments
  • Meet all GIS, State, and NCQA requirements
  • Assists and maintains collections of data, tracking and reporting
  • Assesses business benefit and cost of existing technology-based service or product for competitive advantage
  • Monitors exception processes and outcomes, and recommends process improvements based on trend analysis
  • Interprets and handles highly sensitive investigative activity in preparation for CPC /ongoing sanction activity of at-risk providers.

Background Experience:
  • College degree or equivalent work experience preferred
  • Credentialing experience preferred
  • Experience and or knowledge of NCQA and CMS requirements

Additional Job Information:
  • Proficient computer skills, including proficiency in Microsoft Word and Excel
  • Possess basic project management capabilities
  • Possess a basic knowledge of credentialing accrediting agencies and their standards and guidelines
  • Ability to determine potential for adverse business risk, including good investigation skills
  • Ability to communicate complex ideas in a logical sequence appropriate for the audience

Required Skills:
General Business - Applying Reasoned Judgment, General Business - Demonstrating Business and Industry Acumen, Service - Handling Service Challenges

Desired Skills:
General Business - Ensuring Project Discipline, General Business - Maximizing Work Practices, Service - Creating a Differentiated Service Experience

Functional Skills:
Administration / Operation - Data Entry, Administration / Operation - Document production & distribution, Customer Service - Customer service - transaction based environment, Network Management - Credentialing

Technology Experience:
Desktop Tool - Adobe Acrobat Suite v5, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.


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