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Responsible for assisting, coordinating, planning, and administering the operational and administrative activities for the Credentialing Department under the direction of the Manager, Network Operations.

Assisting with gathering all required credentialing documents by working with Provider Network Account Executives (AE) and reviewing all submitted credential applications for accuracy. 

Coordinating with all providers who qualify for pre-load to our corporate operations department to be loaded in claims adjudication system and submitting complete credentialing application to Corporate Credentialing department.

Serving as the point of contact regarding submitted application for Corporate Credentialing.

Planning and tracking credentialing progress and data for the Plan and identifying trends in credentialing volume.

Assist managers with process improvement as necessary. Assist managers with project planning related to contracting and credentialing workflow processes.

Leads staff in the execution of managing the Credentialing production environment by promoting effective operations through standardization and process improvement such as tracking credentialing progress and data for the plan and identifying trends in credentialing volume, gaps in credentialing documentation submission by AE’s, and communicating new requirements from Corporate Credentialing and the State Contract updates.

Develops new standardized procedures for documentation submission and communicates this to the PNM team.

Implements new procedures and instructs personnel regarding them such as communicating and educating PNM when to use a new credentialing work order versus emailing new documentation and implementing new workflows as document requirements change with new provider types being added to the health plan.

May provide leadership direction and mentoring to Credentialing staff. Ensures the volume of work produced meets or exceeds productivity, timeliness, and quality standards.  

Provides support to all Data Analysis functions as required in maintaining a set work wide database of fully credentialed providers.