Lead - Credentialing Operations Specialist

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* Location:

** Avera Health Plans
** Worker Type:
** Regular
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* Work Shift:

** Primarily days with possible weekends/evenings/holidays (United States of America)
** Pay Range:
*** The pay range for this position is listed below. Actual pay rate dependent upon experience.*$24.00 - $32.25
** Position Highlights
**** You Belong at Avera
**** Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.*
* ** A Brief Overview
** The Lead – Credentialing Operations Specialist plays an integral role on the Avera Health Plan team by supporting the operations and management of Avera Health Plans Provider Credentialing. This role serves as the subject matter expert related to Avera Health Plans provider credentialing for internal and external clients and functions as a resource for credentialing coordinators, Avera Health Plans personnel, vendors and providers.

** What you will do*
* * Oversees daily credentialing operations, ensuring compliance, quality, and timely turnaround of credentialing activities.
* Monitors quality of work by conducting regular audits and tracking results.
* Resource for provider credentialing coordinators on department procedures using advanced knowledge of credentialing, NCQA requirements, State and Federal Credentialing laws and system configuration within the credentialing software system.
* Provides guidance, resolves interdepartmental issues, and serves as credentialing subject matter expert for internal and external departments.
* Monitor shared inboxes and respond within required time frames.
* Support departmental projects and accreditation activities, including NCQA audits.
* Develops and maintains standard operating procedures, job aids and training materials for internal staff and providers completing credentialing.
* Review credentialing files and prepare Level 2 credentialing files for Credentialing Committee meetings.
* Prepares credentialing packets and works with physician Medical Directors for review. Ensures decision process is completed within set time-frames.
* Monitors monthly metrics and aging reports, meeting with other departments to make to make necessary improvements when key performance indicators are not meeting goals.  
** Essential Qualifications
** The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

** Required Education, License/Certification, or

Work Experience:

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* * Bachelor's Healthcare Administration, Business, Health Information or a related field or equivalent years of related experience.
* Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) or
* Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)
* 4-6 years Experience in credentialing within a hospital, insurance or managed care environment.
* In-depth knowledge of provider credentialing processes, regulatory requirements, and industry best practices.  
** Preferred Education, License/Certification, or

Work Experience:

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* * Strong analytical abilities with proficiency in data analysis and KPIs (Key Performance Indicators) development.
* Proven ability to enhance operational efficiency in fast-paced settings.
* Ability to drive continuous process improvements in a fast-paced environment.
* Experience with the following software:
Outlook, Microsoft, Excel, CACTUS/Provider, Epic/Tapestry, Health Trio and Maccess.  
** Expectations and Standards*
* * Commitment to the daily application of…