This position is responsible for coordinating the processes and systems used to support corporate, vendor and delegated credentialing audits. The position responds to, conducts, and documents corporate audit and delegation activities to comply with vendor, corporate and health plan contractual requirements, NCQA/URAC credentialing standards and guidelines, federal, state, and other government regulatory requirements.
This position reports to the Director of Operations and interacts with internal and external customers to promote collegial relationships and respond to executives regarding customer specific concerns. Additionally, this position collaborates with the network credentialing reporting team to ensure the thoroughness and accuracy of all customer deliverables including corrective action plans. This position also supports the corporate-wide audit deliverable. - Audit of provider files, and payer enrollment applications. - Facilitate and perform delegated credentialing audits, complete corrective plans and payer attestations. - Represent payer audit and compliance operations at internal and external meetings. - Train team members on payer audit and compliance procedures. - Point of contact for internal & external communications regarding payer audit and compliance. - Research, complete and maintain compliance with facility and delegated payers through the pre-assessment process, enrollment implementation and ongoing re-enrollment (re-credentialing) requirements - Review and audit of payer implementations, source documentation, reference tools, front and back end systems, policies, and reporting. Interact and work directly with internal and external stakeholders across the country. Additionally, work directly with Payer Relations Implementation team, Regional Directors, the Revenue Cycle Operations Managers & Teams (Accounts Receivable, Payer Enrollment, Billing, Call Center, Individual Credentialing, Clinical Ops Teams, IT, Compliance, Legal, Patient Safety, Marketing and MinuteClinic Field and Operations Management) to ensure integration of all processes.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
1. 3+ years of experience with provider/insurance payer credentialing, enrollment, audit and compliance experience in a multi-state, multi-entity environment
2. 2+ years of experience with Medicare and Medicaid health care programs and government programs and provider enrollment and credentialing regulations and requirements.
3. 2+ years of experience with Microsoft Excel and the Microsoft Office Suite
4. 2+ years of supervisory expereince
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
1. Understanding of credentialing Joint Commission, NCQA, AACME and URAC accreditation/compliance standards
2. Credentialing & Payer Enrollment Management system related experience
3. Excellent written and verbal communication skills including formal presentation
4. Ability to work with teams / impacting & influencing team members and key stakeholders
5. PC proficiency, proficiency in Microsoft Office applications and ability to effectively utilize other software and systems as needed.
6. Critical thinking with the ability to establish and maintain positive relationships
7. Ability to manage and execute under pressure with competing priorities
8. Understand data, reporting and make sound recommendations and decisions based on facts
9. Project management and the ability to participate on multiple cross-functional project teams to achieve on-time results
10. CPCS (Certified Provider Credentialing Specialist) Certification – Optional
HS Diploma or GED is required
Bachelors Degree preferred
Bring your heart to CVS Health
Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
We strive to promote and sustain a culture of diversity, inclusion and belonging every day.
CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.