C2Q Health Solutions · 7 hours ago
CLAIMS AND CREDENTIALING ANALYST
Bronx, NY
Full-time
Onsite
Mid Level
$75K/yr - $85K/yr
3+ years expC2Q Health Solutions is seeking a Claims and Credentialing Analyst to enhance the efficiency of the Provider Data team. The role involves analyzing provider credentialing processes, ensuring compliance with regulations, and conducting claims analysis to drive operational improvements.
Management Consulting
Responsibilities
Coordinate provider credentialing process to increase efficiency and ensure that credentialing deadlines are met
Research and solve credentialing/re-credentialing delays & issues with enrollment in a timely manner
Manage confidential information of internal staff (Physicians, Nurse Practitioners)
Ensure demographic updates are reviewed and verified for processing
Ensure the database is kept accurate and updated
Maintain necessary logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing to ensure requirements are met in a timely manner
Prepare documents for Credentialing Committee review
Outreach to provider for information verification and miscellaneous inquiries, i.e. provider portal access, nursing home documentation, medical records retrieval, etc
Perform in-depth provider claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency
Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements
Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments
Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations
Review monthly capitation payments in accordance with contractual obligations
Perform analysis on capitation payments to determine trends or discrepancies on the payments as well as determine improvements on the process
Prepare analysis on network provider performance through the development of monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirement and identify areas for improvement
Provide productivity and issues reports for Management
Remain current on policies affecting provider credentials and enrollment processes
Other duties as assigned
Qualification
Required
Bachelor's Degree, and/or equivalent work experience
A minimum of three (3+) years of credentialing experience
Microsoft Office/Suite Proficient (Excel, Outlook, Word, etc.)
Highly Organized
Able to multitask efficiently and effectively
Solid problem solving and time management skills
Have the ability to review and draft correspondence in email and word processing systems
Professional, Friendly, and Skillful Communication Skill Set
Individuals must be able to sustain certain physical requirements essential to the job
Standing – Duration of up to 6 hours a day
Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods
Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc
Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job
Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas
Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy
Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy
Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job
Preferred
Credentialing in a Healthplan setting
Certified Provider Credentialing Specialist – Preferred
Company
C2Q Health Solutions
C2Q Health Solutions offers management services tailored to the needs and goals of healthcare providers.
201-500 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase