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Sr Mgr Provider Admin & Credentialing

Role overview

Summary

This role is for managing the credentialing process at HCSC, ensuring compliance with various agency regulations. It involves developing policies and procedures while collaborating with leadership across the organization to enhance operational effectiveness.

Qualifications

  • Bachelor’s Degree and 7 years’ experience in managed care provider contracting, network management or credentialing OR 11 years’ experience in the same fields.
  • 3 years management experience.
  • Experience developing and implementing policies, procedures, processes, and workflows.
  • Knowledge of NCQA, URAC, CMS, and state Department of Insurance regulatory requirements.
  • Analytical skills and experience identifying and resolving workflow and system problems.

Responsibilities

  • Manage the credentialing process in compliance with agency regulations.
  • Develop, implement, and maintain policies, procedures, and workflow processes.
  • Monitor and analyze unit production and quality statistics to ensure achievement of goals.
  • Participate as a Lead in Provider Network Committee and Institutional Provider Workgroup meetings.

Key facts

  • Remote from: United States
  • Full time
  • Senior (5-10 years)
  • Systems Administrator
  • $93K – $168K / year
  • English

Hard skills

Other skills

  • Analytical Skills
  • Innovation
  • Data Reporting
  • Communication
  • Teamwork
  • Coaching
  • Training And Development

About the company

Health Care Service Corporation logo

Health Care Service Corporation

  • Health Insurance & Payers
  • XLarge
  • 10,001+
Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), is an Independent Licensee of the Blue Cross and Blue Shield Association. We are the largest customer-owned health insurer in the United States, serving more than 18.6 million members through our Plans in Illinois, Montana, New Mexico, Oklahoma, and Texas. For nearly a century, we have enabled and coordinated the access to quality care for millions of members. Our experience and industry knowledge establishes a solid foundation for our future—driving innovations that further expand access, improve health outcomes, and reduce costs. Embedded within the fabric of how we operate is a deep sense of caring and commitment that informs how we serve our members, engage in local communities, and deliver positive change to the health care industry. As health care needs evolve, we leverage our portfolio of companies to deliver differentiated value to all industry stakeholders so that, together, we make more possible. Join HCSC and discover what new ways of thinking can mean for you, your community, our customers and our organization: HCSC.com/careers. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to an inclusive, drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability, or protected veteran status.

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Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

SUMMARY:
This position is responsible for managing the credentialing process in compliance with agency regulations (Department of Insurance, CMS, DOD/TriCare, NCQA and URAC), managing the process of collection and maintenance of professional provider data, and managing credentialing audits. This position is responsible for the development, implementation and maintenance of policies, procedures, workflow processes and developing departmental goals, ensuring the departments meets or exceeds goals, and operational effectiveness. Develop performance standards, monitor and analyze unit production and quality statistics to ensure achievement of goals while ensuring personnel resources are appropriately allocated. Participate as a Lead in monthly Provider Network Committee and quarterly Institutional Provider Workgroup meetings, working with Vice Presidents, Directors and Managers from across state and the Enterprise to address issues and improve processes.

JOB REQUIREMENTS:

  • Bachelor’s Degree and 7 years’ experience in a managed care provider contracting, network management or credentialing OR 11 years’ experience in a managed care provider contracting, network management or credentialing
  • Must have 3 years management experience.
  • Management skills to cultivate a creative, supportive and innovative environment.
  • Coaching and training skills.
  • Experience in a production environment with a focus on operations, state and federal regulations, industry standards and quality concepts.
  • Experience developing, implementing and managing projects and programs.
  • Experience developing and implementing policies, procedures, processes, and workflows.
  • Knowledge of NCQA, URAC, CMS, and state Department of Insurance regulatory requirements.
  • Analytical skills and experience identifying and resolving workflow and system problems.
  • Written, verbal and interpersonal communication skills. 
  • Ability to present clear, concise and accurate information.
  • Ability to facilitate diverse groups and build relationships with employees and external customers.

PREFERRED JOB REQUIREMENTS:

  • Proficiency in data tools (Excel, PowerBI, data mining, data reporting) - HIGH PREFERRED
  • Knowledge of HCSC provider systems.
  • Experience developing innovative solutions to ensure objectives are accomplished.

Sponsorship will not be provided for this role.

This is a Telecommute (Remote) role.

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Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees.  Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.

Base Pay Range

$92,700.00 - $167,500.00

Exact compensation may vary based on skills, experience, and location.

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