Independence Blue Cross · 5 hours ago
Senior Credentialing Compliance Analyst (Hybrid) - (PA/NJ/DE)
Philadelphia, Pennsylvania
Full-time
Hybrid
Mid, Senior Level
3+ years expIndependence Blue Cross is seeking a dynamic individual to join their Quality Management team as a Senior Credentialing Compliance Analyst. This role is responsible for overseeing quality and compliance with accreditation and regulatory requirements, conducting audits, and analyzing data related to credentialing operations.
Health CareHealth InsuranceInsuranceMedical
Responsibilities
As a part of the Quality Management team, the Senior Credentialing Compliance Analyst implements policies related to practitioner and ancillary credentialing for all provider types
This includes adherence to procedures for ongoing monitoring of practitioner sanctions, complaints, and quality issues between recredentialing cycles and taking appropriate action when it identifies occurrences of poor quality
Implementation includes ongoing monitoring of providers by surveilling practitioner sanctions (inclusive of Medicare and Medicaid sanctions, state sanctions, restrictions on licensure, and/or limitations on scope of practice), complaints, and quality issues on an ongoing basis and initiating appropriate action based on these reviews
This includes assessment of legislation in PA and surrounding states, all state licensing bureaus, CMS standards and NCQA requirements
Dedicated to analyzing reports to identify high-risk, high-volume, and problem-prone processes to mitigate risk
Performs follow up analysis of reports to determine accuracy of data components
Formulates recommendations based on best practices and cross-functional business operations and collaborates with business area to execute follow up of corrective action plans
Develops and maintains corporate credentialing business decisions as needed
Qualification
Required
Minimum of 3 years' experience in one or more of the following areas: Credentialing Operations, Network, Corporate Compliance or Quality Management required
Comprehensive knowledge of credentialing procedures, accreditation and regulatory requirements relating to credentialing
Requires several years of work experience in healthcare compliance, or a related field
Key skills include strong analytical, investigative, and decision-making abilities, as well as experience reviewing legal and medical information
Possesses excellent organizational skills and ability to manage demanding workload; initiative-taking; able to fulfill responsibilities with minimum supervision
Demonstrated ability to work independently, handling situations that require independent judgment
Demonstrated ability to manage specialized electronic database, run reports and analyze data
Demonstrated ability to interact with diverse groups of people within the organization and with outside agencies
Possesses the analytical skills necessary to follow up information provided on physician and allied health applications
Requires ability to pay meticulous attention to detail and to respond to requests for information
Adheres to professional confidentiality standards in accordance with legal, ethical, and departmental policies
Manages sensitive and confidential situations/information with a high degree of tact and diplomacy
Exhibits excellent people skills, including those required for customer service
Preferred
A bachelor's degree in a related field such as business administration or health services administration is preferred
Comprehensive experience with Microsoft Office Suite, excellent organizational, presentation, interpersonal, verbal, and written communication skills
Knowledge of statistical sampling techniques preferred
Experience with specific regulations, such as those from the Office of Inspector General (OIG), is especially valuable
Company
Independence Blue Cross
The leading health insurer in southeastern Pennsylvania. It is a sub-organization of Independence Blue Cross.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Alexandra Jorgensen
Senior Vice President Human Resources
Joe Geist
SVP & Market President, National
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