About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The credentialing associate will perform a variety of credentialing/recredentialing activities such as processing provider applications to ensure the integrity of the applications, compliance with NCQA Standards and Guidelines and State and Federal regulatory guidelines. The credentialing associate will maintain provider credentials data and enter all relevant information into the credentialing databases. Respond to provider inquiries and work closely with Provider Relations, Contract Managers, and other internal departments to resolve issues.

Primary Job Responsibilities: 

• Process credentialing and recredentialing applications to ensure the integrity of the applications and compliance with NCQA, State and Federal guidelines and Fallon Health Credentialing policies and procedures.
• Under limited supervision, applies credentialing knowledge and skills to perform a wide range of moderately difficult tasks and assignments requiring judgment in resolving issues and/or in making                                            recommendations.
• Prepare second levels with detailed information for Credentials Committee review.
• Participates in delegation oversight file audits.
• Maintain and update eVIPs with individual provider credentials and recredentialing status, tracking pending/completed applications while maintaining a complete and accurate databased of historical information for all            providers.
• Responds to all inquiries from all internal and external customers.
• Conduct follow-up as needed to ensure that all credentialing/recredentialing is completed with state and department required timeframes.
• Complete daily rosters by adding providers to CAQH and CVO to initiate credentialing.
• Monitor and research non-responder notifications to ensure provider applications are completed timely.
• Prepare the Committee Listing (M-TH) for submission to the Credentials Committee Chairperson for review and approval.
• Identify automation opportunities to reduce manual work resulting in improved efficiency
• Print and mail provider notification letters at the FH corporate office located at 10 Chestnut Street, Worcester, MA several times per month or as needed, as designated through a rotational in-office calendar or at the              direction of a supervisor or manager.

Education: 

Bachelor's degree or equivalent combination of training and experience. 

Experience:

Two years related experience, preferably in health care

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.