Senior Credentialing Specialist

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit Amida Care for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced leader to join our team as the Senior Credentialing Specialist. Compensation will be commensurate with experience.

Position Summary :

Under supervision of the Director of Ancillary and Credentialing & Provider Enrollment, the Senior Credentialing Specialist is responsible for all aspects of the Credentialing / Recredentialing processes. Duties include ensuring the health plan and its providers comply with regulatory and accrediting agencies, interpreting standards, and identifying, recommending, and implementing changes.

Responsibilities :

• Reviews and screens Initial and Re-credentialing, Ancillaries and HIV Attestation Renewal applications for completeness, accuracy, and compliance with NCQA Standards and Conducts primary source verification, collects and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing Policy and Procedure.
• Conduct, coordinate, and document credentialing and recredentialing activities to ensure compliance with state, federal, NCQA, and internal requirements.
• Evaluate performance of delegated entities and review submitted reports for completeness, accuracy, and timeliness when applicable.
• Identify deficiencies or non-compliance in delegated activities and develop appropriate corrective action plans, track follow-up through resolution.
• Collaborate with internal teams and delegated entities to ensure consistent adherence to credentialing delegation standards and contractual obligations if assigned.
• Assist in the planning and facilitation of credentialing / credentialing Oversight Committee meetings, including preparation of agendas, presentation materials, and follow-up documentation.
• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies; prepares and provides information to internal and external customers as appropriate.
• Participates in the development and implementation of process improvements for the system-wide credentialing process.
• Communicates clearly with providers, their liaisons, as needed to provide timely responses upon request on day-to-day credentialing and privileging issues as they arise.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.
• Ability to communicate effectively both orally and in writing.
• Customer service skills.
• Ability to respond to emails timely and effectively.
• Knowledge of NCQA provider credentialing standards, requirements, accreditation principles, policies, processes, procedures, and documentation.
• Ability to use independent judgment and to manage and impart confidential information.
• Ability to maintain confidentiality and discretion in all communications on behalf of credentialing applicants and / or applications.
• Demonstrated advanced working knowledge of Microsoft Word and Excel.
• Skill in establishing priorities with independent coordination of day-to-day aspects.
• Special projects as assigned.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

EXPERIENCES AND / OR SKILLS REQUIRED