Senior Credentialing Representative – Quality Auditor

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.  

Location: Remote, Nationwide

Schedule: Monday to Friday, 8 AM- 5 PM

The Senior Credentialing Representative is responsible for ensuring that credentialing information and data meets internal and external quality standards and requirements. Internal audits are performed against established standards for all credentialing and recredentialing functions within the Credentialing Center of Excellence (CCoE). The SCRA will document findings, identify trends, and recommend opportunities for improvement.

You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities

Credentialing File Review/Audit:

• Performs daily audits of credentialing and recredentialing files utilizing standardized audit template
• Ensures audits are performed within established timeframes
• Communicates identified errors to credentialing representatives and specialists utilizing established processes

Process improvement:

• Participates in audit result review and track and trend of results
• Participates in root cause analysis
• Reviews repeat errors for potential training opportunities
• Provides explanations and interpretations within area of expertise
• Identifies potential process improvement needs to workflows and procedures
• Communicates potential and identified trends to leadership

Delegation Oversight:

• Collect and review credentialing files and materials for submission to delegating health plans at time of initial and annual delegation oversight audits
• Collect and review submitted sub-delegated files and materials at time of pre-assessment and annual delegation oversight audits
• Other department duties as assigned

Knowledge, Skills, and Abilities:

• Demonstrated understanding credentialing information processes 
• Established knowledge of credentialing requirements to include NCQA, CMS, and state-specific regulations
• Attention to detail, ability to identify inconsistencies and missing information
• Analytical and critical thinking skills
• Ability to research and evaluate credentialing criteria when questions or discrepancies are presented
• Strong communication skills, ability to communicate clearly and professionally in written or oral formats
• Ability to identify problems, analyze data and recommend solutions
• Ability to maintain confidential information in accordance with Company policies, state, and federal regulations
• Ability to manage detail and work with accuracy 
• Ability to acquire knowledge of technical resources within the organization
• Ability to work independently
• Ability to establish and maintain cooperative working relationships with individuals at all levels including teammates from other teams
• Ability to work with frequent interruptions
• Ability to prioritize work and skill in working effectively under deadlines and changing priorities
• Demonstrated knowledge of Microsoft Office applications such as Word, Excel, and Outlook

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.