Senior Credentialing Research Specialist

at  Magellan Health

This position is responsible for various activities related to support of the Credentialing Operations department. These activities may include serving as the credentialing liaison to Network/Network Operations teams, research of credentialing-related criteria and requirements, outreach to providers regarding application/practice history, and maintenance of resources utilized by the credentialing operations team. Additionally, this position may support the audit and oversight functions for delegated credentialing and serve as the credentialing point of contact during customer and accreditation audits. Incumbent will provide support and backup to the Credentialing Manager and interact with all stakeholders, as needed, to ensure efficient, compliant credentialing processes.

• Collaborates intra-departmentally on research and resolution of issues, the design and execution of reports, communications, process changes, and training materials, ensuring alignment amongst key stakeholders.
• Supports NCQA and customer required pre-assessment and oversight of provider groups to whom Magellan delegates credentialing responsibilities.
• Serves as credentialing point of contact during customer and accreditation surveys of the Magellan credentialing process.
• Manages criteria/legal review process. Safeguards sensitive, protected information in the execution of this task. This activity may include confidential outreach for documentation pertaining to adverse application information.
• Monitors and completes annual tracking education and training evidence to be gathered from approximately 800 state license boards. Ensures evidence is obtained timely and in accordance with NCQA standards.
• Performs detailed research regarding credentialing criteria and processes, as requested by internal customers.
• Ensures credentialing policies, guidelines, and resources align with regulatory, contractual and Magellan requirements.
• Provides leadership to Credentialing Operations team as required and requested by Credentialing Manager.
• Leads the effort to ensure policies are reviewed and updated timely and works with non-credentialing stakeholders to obtain policy alignment.
• Professionally represents Credentialing Operations in internal and external meetings, including with Senior Leadership.

WORK EXPERIENCE - REQUIRED

Credentialing, Quality

EDUCATION - REQUIRED

High School

EDUCATION - PREFERRED

Bachelor’s

RESPONSIBILITIES

Minimum of 5 years credentialing or health plan contracting (or equivalent) experience.
Knowledge of National Committee for Quality Assurance (NCQA) credentialing standards.
Experience with internet research, review and analysis.
Intermediate knowledge of Microsoft Office applications (Excel, Word, Outlook).
Strong written communication and presentation skills.
Ability to work independently and prioritize activities.
Proven ability to establish consensus, negotiate outcomes, and team build effectively.

This position is responsible for various activities related to support of the Credentialing Operations department. These activities may include serving as the credentialing liaison to Network/Network Operations teams, research of credentialing-related criteria and requirements, outreach to providers regarding application/practice history, and maintenance of resources utilized by the credentialing operations team. Additionally, this position may support the audit and oversight functions for delegated credentialing and serve as the credentialing point of contact during customer and accreditation audits. Incumbent will provide support and backup to the Credentialing Manager and interact with all stakeholders, as needed, to ensure efficient, compliant credentialing processes.

• Collaborates intra-departmentally on research and resolution of issues, the design and execution of reports, communications, process changes, and training materials, ensuring alignment amongst key stakeholders.
• Supports NCQA and customer required pre-assessment and oversight of provider groups to whom Magellan delegates credentialing responsibilities.
• Serves as credentialing point of contact during customer and accreditation surveys of the Magellan credentialing process.
• Manages criteria/legal review process. Safeguards sensitive, protected information in the execution of this task. This activity may include confidential outreach for documentation pertaining to adverse application information.
• Monitors and completes annual tracking education and training evidence to be gathered from approximately 800 state license boards. Ensures evidence is obtained timely and in accordance with NCQA standards.
• Performs detailed research regarding credentialing criteria and processes, as requested by internal customers.
• Ensures credentialing policies, guidelines, and resources align with regulatory, contractual and Magellan requirements.
• Provides leadership to Credentialing Operations team as required and requested by Credentialing Manager.
• Leads the effort to ensure policies are reviewed and updated timely and works with non-credentialing stakeholders to obtain policy alignment.
• Professionally represents Credentialing Operations in internal and external meetings, including with Senior Leadership