Manager of Credentialing and Provider Data

Operations Park Ridge, Illinois


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets, employees.

Clear Spring Health

Manager of Credentialing and Provider Data

Park Ridge, IL

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina through our affiliate, Eon Health (redirects to Eon).

Group1001 is on a mission to empower consumers. Our family of companies share a common goal: giving people more control over their money, making it easier for them to do businesses with us, and creating more opportunities for them to see value every day.

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture.

One of the goals for Group1001 is to foster a great culture.  Group1001 will continue to build a culture that emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets, employees. 

Job Summary:

Performs the operations of all credentialing and provider data management functions ensuring compliance with National Committee for Quality Assurance (NCQA), Center of Medicaid/Medicare Services (CMS) and other regulatory standards. Performs all reporting and data requirements for the health plan, including but not be limited to such activities as: network development reporting, provider data reporting and data comparisons for startup and ongoing operations, extractions for directory submissions, maintenance of data among multiple systems for integrity, operational scorecards, and other reporting and data requirements as defined by the plan.

Main Accountabilities:

  • Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications and ensures the process between credentialing and provider data integrity is seamless
  • Ensure compliance with CMS, NCQA and DHHS credentialing requirements and participate in activities related to plan NCQA accreditation
  • Facilitate Credentialing Committee activities and serve on Quality Improvement Committees, when needed
  • Manage provider directory process to ensure accuracy and compliance
  • Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives
  • Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies
  • Direct oversight and coordination of GeoAccess reports and provider network reports required for submission to CMS on an ongoing basis
  • Accountable for any ad hoc reporting needs as defined by the health plan
  • Ensure all provider data entries and updates are completed accurately and timely
  • Manage and monitor provider data integrity, accuracy, and trending
  • Other duties as assigned
  • Conduct audits on provider setup and credentialing

Qualifications: 

  • Bachelor’s degree in Business Administration, Communications or related field
  • 5+ years of provider data management, credentialing or healthcare operations experience (i.e. claims processing, billing, provider relations or contracting)
  • Experience performing data analysis in MS Excel or similar tools is required
  • Experience in a managed care or insurance is required
  • Immaculate attention to detail and excellent proofreading skills