Purpose:
UPMC Health Plan is hiring a full time Credentials Analyst. In this role you will ensure that the provider files comply with UPMC Health Plan credentials standards prior to submission to the Credentials Committee. You will assist in maintaining department compliance with all governing bodies. The Credentialing Analyst is responsible for coordinating the timely credentialing activities that are necessary to support the credentialing and recredentialing of UPMC Health Plan direct contracted providers and to provide support to the UPMC HP Network staff. You will also assist with data base maintenance and integrity.

This is a hybrid position and will require an in-office presence at least 3 days per week.

Responsibilities:

• Review credentials/recredentials applications for completeness. 
• Written and verbal communication with provider to obtain information necessary to complete application.
• Ensure customer service to both internal and external customers. Respond promptly, courteously and accurately to credentials questions from UPMC HP departments, UPMC HP providers and UPMC HP PHO/PO affiliates.
• Complete primary source verification information, including verification of applicant's license, board certification, hospital privileges, malpractice history, residencies, graduate medical education. 
• Check for sanctions using appropriate verification sources. 
• Obtain copies of Medical License, DEA certificate, and malpractice insurance face sheet.
• Prepare provider files for credentialing and recredentialing within 60-180 days of the provider's signature on the application according to UPMC HP policies and procedures.
• Perform data entry for fields that Credential department is responsible for on an ongoing basis to assure correct credentialing information in the directories. 
• Review and update of information in the CACTUS database.
• Maintain the correct Availability status in Teams platform. 
• File documents in the provider's file as they are received. 
• Update credentials data in Health Plan databases according to department standards. 
• Prepare the Exception packets for the monthly Credentials Committee meeting. 
• Attend the Credentials Team meetings as scheduled.
• Outreach providers by phone, email, or fax in a timely manner. Capturing communication in the Notes section of the Verification Instance. Dated and initialed.

• Associate degree in business or healthcare (Experience in business, healthcare or customer service may be substituted for educational requirements); Bachelor's degree preferred. 
• Two years' experience in credentialing preferred. 
• Experience in NCQA compliance in credentialing preferred. 
• Computer efficiency in database entry, Excel, word processing and report generating essential. 
• One year of data entry or related experience preferred.
  
  Licensure, Certifications, and Clearances:
   

• Act 34

   

  
  UPMC is an Equal Opportunity Employer/Disability/Veteran