Credentialing Tech, Lead-CPMSM or CPCS certification required

Trains new employees in Credentialing Services, and conducts the ongoing training of existing employees on BCBSAZ, TriWest and URAC credentialing requirements for both individual and institutional credentialing; responsible for the development of training manuals and supporting documentation.

• Responsible for the organization and performance of credentialing/recredentialing activities of Blue Cross and Blue Shield of Arizona (BCBSAZ) and TriWest Healthcare Alliance providers. This includes primary source verification, review of data, data input, assembly of required documentation, generation of reports, filing, communication with physicians and other health care providers, and preparation of information for the Credentials Committee.

REQUIRED QUALIFICATIONS

• 5 years of experience in business office with increasing responsibilities field

• 3 years of experience in credentialing process in a managed care organization or hospital field

Required Education

• High-School Diploma or GED in general field of study

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Required Licenses

• N/A

Required Certifications

• Certified Professional in Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS )

PREFERRED QUALIFICATIONS

• N/A

• Associates Degree in general field of study

• N/A

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

LEVEL 1:

• Develop and maintain training manuals for individual and institutional credentialing processes.
• Provide training to new credentialing employees on the BCBSAZ, URAC and TriWest credentialing requirements.
• Monitor files of new employees to ensure compliance with the BCBSAZ, URAC and TriWest credentialing requirements.
• Train all credentialing employees on new processes or use of new websites for credentialing verification purposes.
• Perform primary source verifications of such items as licensure and education for individual providers per written Credentialing policies and procedures.
• Review provider credential files against defined criteria to determine whether providers meet BCBSAZs credentialing guidelines.
• Maintain accuracy and completeness of credentialing files and ensure consistency with URAC, TriWest and BCBSAZ standards.
• Prepare files for Credentials Committee meetings.
• Correspond effectively with providers, BCBSAZ, TriWest and other outside agencies, both verbally and in writing, to assemble and communicate credential/recredential information.
• Perform computer data entry and generation of reports.
• Develop and maintain desktop procedures for all credentialing/recredentialing activities as well as training manuals as directed.
• Compile, submit and maintain statistical workload reports for department analysis.
• Along with the Credentialing Manager, is responsible for the quality management program for credentialing, including monitoring of the quality improvement projects.
• Maintain thorough knowledge of provider files, and applicable credentialing and/or contracting databases.
• Participate in continuing education to maintain certification, if applicable; attend courses offered by BCBSAZs Corporate Training and Development department and the Health Services Division; participate in computer-related educational offerings as related to position function.
• Participate on internal committees as necessary to maintain a current general knowledge of the company products, goals and functions.
• Maintain standards of ethical practice and confidentiality.
• Apply appropriate security and privacy measures to all tasks.

• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned .

LEVEL 2:

• Must be proficient in all job functions in Level 1
• Acts as the system administrator for the National Practitioner Databank (NPDB), including the Proactive Disclosure System (PDS), and for any other accounts necessary for primary source verification of credentials
• Acts as a liaison between BCBSAZ and the Arizona Department of Health Services (AzDHS) for all research regarding licensure and facility types
• Acts as a liaison between BCBSAZ and professional licensing boards for all changes in statutes and scope of practice questions

• Acts as a liaison between BCBSAZ and AzDHS as well as professional licensing boards regarding mental health parity questions
• Conducts extensive research when necessary to assist in the implementation of new license types or the changes of license types by either AzDHS or the professional licensing boards
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned

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