Credentialing Professional

If you're someone who loves details, organization, and making sure everything is just right, this could be the role for you! You will keep our provider network running smoothly. You will manage credentialing and recredentialing, maintain accurate provider records, support compliance and audits, and improve the way we work. Reporting to the Credentialing Supervisor, you will be a part of a dynamic team supporting the WI Medicaid Market.

Main Responsibilities:

• Credentialing Operations:
  Performing initial and recredentialing for practitioners and organizational providers following established requirements.

• Compliance and Regulatory Oversight:
  Ensure credentialing activities meet NCQA, state Medicaid, DHS, CMS and internal policy requirements.

• Quality and Auditing:
  Maintain complete, accurate credentialing records and support audits and file reviews.

• Provider Data and Network Integrity:
  Maintain accurate provider records, monitor ongoing credentialing requirements, and coordinate provider and practitioner status changes with appropriate departments.

• Workflows:
  Monitor credentialing turnaround time, resolve discrepancies, and contribute to process improvement.

• Provider and Internal Department Coordination:
  Colloborate with network development, provider relations, contracting, compliance and external credentialing vendors to resolve discrepancies to ensure providers meet participation requirements.

• Associates degree or have a Certified Provider Credentialing Specialist certification

• 3 or more years of experience in credentialing and recredentialing

• 2 years of experience working in Adobe and Microsoft applications

• 1 year of experience with audit preparation, file reviews, and identifying documentation deficiencies

• Understanding of NCQA requirements, DHS and CMS regulations

• Work between 8:30-5:00pm CST, Monday through Friday

• Bachelor's Degree in Business or a related field

• Reside in WI

• Knowledge of state regulations on compliance in the insurance industry

• Managed Care Organization experience

• Advanced experience working with NCQA standards

• Experience working with governmental agencies

• Workstyle: Home

• Work Days/
  
  Hours:
  
  Monday – Friday, 8:30 am – 5:00 pm Central Standard Time (CST)

Work at Home Requirements:
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

40

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$58,700 - $70,400 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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