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Provider Credentialing & Elig Analyst Sr Job

Date: Jan 4, 2019

Location: Eagan, Minnesota, US, 55122

Company: Blue Cross and Blue Shield of Minnesota

For more than 80 years, Blue Cross and Blue Shield of Minnesota has been passionate about improving health. We provide quality, cost-effective health plans and innovative programs that make a healthy difference in people’s lives. Blue Cross is the largest health plan based in Minnesota, covering nearly 3 million members in the state and across the country. We strive to help all Minnesotans overcome the barriers to good health.



 



We offer our employees a comprehensive benefits, compensation and total rewards package to keep you and your family healthy and to secure your financial future. Our Employee Resource Groups help us advance health equity while promoting a diverse and inclusive work environment. Join us and make a healthy difference in people’s lives through the work you do every day. Together, we'll make Minnesota a better place to live — and a healthier one.


Description Summary

This self-motivated individual is responsible for managing and coordinating the committees who review complex practitioner and provider credentialing and eligibility issues. The senior analyst also prepares individual case work for these committees involving researching and coordinating complex practitioner and provider credentialing and eligibility issues to assure that practitioners and providers comply with Federal, State, BCBSA and BCBSMN accreditation and audit requirements.


Accountabilities


  1. Manage all aspects of preparation and facilitation for Credentialing and Appeal Committees.

  2. Understand and Monitor NCQA and HEDIS regulatory accreditation requirements for Credentialing Standards. Take ownership for incorporating new and existing regulatory, accreditation or contractual requirements to new or ongoing projects (this includes policy writing, procedure documentation and time management).

  3. This position must perform at a consistently high level in the areas of analyzing, organizing, developing, documenting and presenting practitioner special case issues.

  4. Investigate and coordinate complex practitioner credentialing issues through contact with international and federal government agencies, medical boards and other sources.

  5. Initiates research and analytical review of practitioner credentialing issues for compliance with network participation requirements.

  6. Prepares and documents individual practitioner case summaries based on research findings.

  7. Performs monthly review of state licensing disciplinary actions taken against individual clinicians. Compares findings to network database and initiates proactive steps to ensure quality standards and compliance.

  8. Research and respond to Triage review of practitioner quality and eligibility issues. Evaluate according to credentialing policy and business processes and document the review.

  9. Collaborate with internal and external customers regarding practitioner compliance issues.

  10. Supports Principal Credentialing Analyst with delegated credentialing.

  11. Lead training and mentoring of staff.

  12. Participates in other assigned projects and internal/external workgroups.


Requirements


  • Bachelor's Degree, 5 years credentialing managed care experience, or 9 years of related work experience in lieu of a degree.

  • Ability to work independently and demonstrate advanced problem-solving skills.

  • Ability to apply expertise and knowledge of national and state credentialing standards, internal credentialing policies, practitioner participation requirements, data privacy laws and provider agreements.

  • Ability to effectively communicate the results of research to multiple audiences in both verbal and written forms.

  • Ability to apply advanced knowledge of computer and software applications, including Microsoft Word, Excel, Access, and PAandR.


Preferred Requirements


  • Experience working in Vistar and PAandR.

  • CPCS certification.


FLSA Status

Exempt


Blue Cross Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Make a difference



Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day



Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association


Nearest Major Market: Minneapolis

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