Credentialing Committee Specialist - Hybrid in San Antonio, TX

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.

An ideal candidate for this role would have a passion for supporting our values of Integrity, Compassion, Relationships, Innovation and Performance while utilizing their attention to detail, investigative and communication skills to contribute to a high performing environment with a patient safety focus.

As an independent contributor on our large, diverse credentialing team, you would work in a fast paced/energetic environment working to make impactful connections with medical directors, practitioners, and other key stakeholders and team members during monthly committee meetings and daily interactions. This position is responsible for monitoring credentialing standards and data and facilitating meetings. This role offers the best of both working worlds with a 3 day Hybrid in-office and 2 days remote work schedule that allows for collaboration and flexibility.

If you are located in San Antonio, TX, you will have the flexibility to work from home and in the office in this hybrid role* as you take on some tough challenges.

Primary Responsibilities:

• Identify practitioner administrative and professional issues that require additional investigation and evaluation of discrepancies and follow up with practitioners to obtain clarification or documentation of noted issues
• Communicate adverse, incomplete, or questionable data to Medical Director, Credentials Committee, and credentialing leadership and recommend appropriate course of action. Maintain strict confidentiality and apply professional discretion when areas of concern are identified
• Responsible for Credentialing Committee meeting functions to include:
• Preparing individual files, committee packets, agendas, minutes and follow-up/pended action items documentation
• Scheduling and attending pre-meetings and committee meetings with all committee representatives and meeting attendees
• Maintain knowledge of current health plan credentialing standards and ensures compliance with applicable federal and/or state laws, regulations regulatory requirements to meet standards
• Assist with auditing completed credentialing files to ensure compliance with current policies and procedures/accreditation standards and provide feedback and education to specialists
• Complete and maintain monthly monitoring for sanction, debarment, and exclusion checks to include license sanctions/orders, OIG, and Medicare Opt Out and Preclusion checks
• Prepares and sends regular correspondence to medical directors and key stake holders
• Assists with review and updating of criteria and credentialing policies and procedures as necessary
• Prepares and provides regular quality and credentialing reports to the credentials committee, internal departments and external partners

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 5+ years of general credentialing experience to include running primary source verifications and sanctions/exclusion verifications for OIG, Opt Out, Board Order notifications, etc.
• 2+ years of experience in preparing credentialing and/or special review files and reports for committee presentation
• Experience with sending and/or presenting professionally written communication to medical directors, physicians and other key stakeholders (i.e. requests for confidential information, file summary reviews, committee reports, credential approval notifications, etc.)
• Experience with analyzing provider information against required NCQA or other credentialing standards to ensure compliance
• Experience investigating provider credentialing application discrepancies and obtaining explanation/resolution for credentialing eligibility
• Ability to manage multiple priorities and ensure timely and accurate completion of job duties (i.e. daily file review, credentialing compliance tracking and reporting, advanced meeting material preparation and submission to participants, monthly/quarterly report preparation and submission, etc.)
• Experience working directly and communicating with medical director level leadership
• Ability to confidently speak with and send/present professionally written communication to medical directors, physicians, and other key stakeholders across the organization to facilitate and execute credentials committee meetings and support departmental processes on an ongoing basis
• Ability to work independently and in a team environment
• Proficiency in Microsoft Office Suite and other applications to include Word, Excel, Outlook and Adobe
• Ability to work onsite 3 days of each week

Preferred Qualifications:

• CPCS certification
• Solid knowledge of NCQA credentialing standards and other federal and state (FL, NM, TX) regulatory requirements
• Experience in managed care credentialing

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.