Credentialing Analyst, Infusion Clinics​/Nursing

Credentialing Analyst, Infusion Clinics/Nursing

Hybrid: This role requires associates to be in-office 1-2 days per week
, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law

The Credentialing Analyst, Infusion Clinics/Nursing performs more complex activities in support of provider credentialing to include additional research, auditing, managing credentialing appeals, special projects, delegation oversight, and site visits.

• Performs credentials file audits to ensure timeliness of processing, quality of documentation, and adherence to company and department policies.
• Performs quality review of files to determine accuracy and completeness of all necessary documentation for Medical Director and Credentials Committee.
• Analyzes performance data to predetermined standards.
• May also perform site visits of provider offices for participation in networks.
• Interacts with physicians, office managers, credentialing staff from other organizations to obtain information, provide status updates, research issues necessary for Credentials Committee review.
• Utilizes internal systems and runs reports/queries to research provider questions and resolve issues.
• Monitors license actions, complaints, and sanctions and obtains necessary information for Managers review.
• Prepares documentation for Medical Directors consideration of off-cycle review.
• Maintains provider peer review information on the credentialing database system.
• Supports and tracks provider appeals process.
• May assume responsibility for delegation oversight activities.
• Participates in accreditation survey preparation via data entry, reporting, and acting as task force liaison.

Requires a H.S. diploma or equivalent and minimum of 3 years experience in a managed care environment; or any combination of education and experience, which would provide an equivalent background.

• Knowledge of Medicaid, Medicare, managed care, and PBM providers.
• Experience administering provider/pharmacy credentialing and re-credentialing to meet regulatory, accreditation (e.g., URAC/ACHC), and managed care plan requirements.
• Experience tracking, organizing, and maintaining credentialing files and time-sensitive renewals (electronic and paper), ensuring accuracy and confidentiality.
• Experience serving as a credentialing troubleshooter, resolving payer/PBM-related issues and credentialing delays.
• Experience managing state Medicaid processes (new applications, renewals/revalidations), including portal maintenance, user access administration, and pulling remits as needed.
• Experience with Medicare PECOS processing, NPI (NPPES) updates, and maintaining NCPDP profiles for multiple pharmacy sites.
• Experience coordinating pharmacy site and pharmacist licensing (new applications, renewals, Pharmacist-in-Charge changes) and maintaining license tracking tools.
• Experience supporting payer and compliance documentation needs (e.g., Certificates of Insurance, Fraud/Waste/Abuse attestations, credentialing document collection for applications/RFPs) and collaborating with billing, clinical, and admissions teams.
• Certified Provider Credentialing Specialist and college course work.

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of…