UM & Credentialing Support Coordinator

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person Care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 3,500 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 10 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing costs.

The UM & Credentialing Support Coordinator is responsible for providing support with administrative and operational functions within the Prior Authorization and Credentialing departments. Specifically, this includes UM and Credentialing Committee preparations and post committee functions, Health Plan reporting and audits, record keeping, and project management.  The UM & Credentialing Support Coordinator works closely with the Director of Credentialing and Prior Authorization, department staff, and Medical Directors to maintain regulatory and health plan requirements while building positive customer service outcomes and relationships with our internal and external partners.

Position Duties

• Reviews weekly, monthly, quarterly, and annual health plan reports for errors and compliance issues, makes corrections as needed, and submits to health plan on behalf of the Director.
• Participates in bi-monthly and quarterly Health Plan audits.
• Generates quarterly and semi-annual UM reports for each health plan and data enters the results into the appropriate UM Work Plan and notifies Director once accomplished.
• Prepares agendas, sends meeting invites, confirms attendance, takes meeting minutes, and prepares presentation for Committees bi-monthly and quarterly.
• Finalizes all post committee documents with management’s signatures on UM/CR documents, accepting final changes on policies and programs, updating the TOC and publishing to the employee resource folder including archiving the previous versions, and notifies Department heads.
• Sends out Confidentiality Statements to internal and external members for both committees annually including new members, as needed.
• Requests check approvals from the COO for payment for external committee members participating in UM and Credentialing Committees and confirms attendance with the accounting department.
• Assists in preparation of audit files for NCQA certification for UM and Credentialing and Health Plan audits.
• Assist in reviewing, testing, and implementing CMS and Health plan letter templates.
• Manages and tracks the Policy and Procedures table of contents (TOC) for both Credentialing and Prior Auth to ensure policies and SOPs are reviewed annually by the Director, Prior Auth Supervisor and Credentialing lead.
• Generates reports for auditing prior authorization and credentialing staff each month and notifies Credentialing Lead, PA Supervisor and Director by the 5^th of each month.
• Assists on signing off on all Credentialing check sheets.
• Generates post-committee audit reports for credentialing and notifies Director to review.
• Closes approved credentialing files and removes providers from CAQH roster post-committee.
• Sends approval letters to providers and HDOs after each Credentialing meeting.
• Sends Recredentialing letters to providers and HDOs each month.
• Serves as a secondary contact with regulatory agencies for reporting requirements and ensures ongoing compliance is met with regulatory and accreditation agencies including, but not limited to, CMS, NCQA and contracted health plans.
• Anticipates customer needs: Understand the wants and needs of customers, practices active listening in order to identify cues and formulate appropriate plan of response and what level of intervention is needed.
• Demonstrates the ability to meet deadlines and follow through with requests, sharing of critical information and responding to management and other individuals in a timely manner.
• Collaborates with Director regarding identified opportunities for improvement and ensure implementation of all necessary changes.
• Has current knowledge of all insurance contracts, including but not limited to HMO, PPO, private, and Medicare.
• Maintain awareness of advances in health care, government regulations, and health insurance changes.
• Other duties or special projects as assigned.

Education, Training & Experience

• GED or High school Diploma
• Minimum of three years healthcare administrative experience with demonstrated excellent communication, attention to detail and problem solving skills.
• Demonstrated knowledge of managed care systems, NCQA, and CMS standards for Credentialing & Utilization Management.
• Excellent knowledge of computer applications, including Word, Excel, Outlook, Power Point.
• Demonstrates exceptional time management and organizational skills.
• Demonstrated excellent customer service etiquette skills, orally and in writing.
• Demonstrated ability to work within a team environment and creatively to achieve organizational goals.

*This is a hybrid position, effective after first 90 days of mandatory in-office training*