Senior Credentialing & Vendor Operations Specialist

About the role

Location: Avera Health Broadband Lane

Worker Type: Regular

Work Shift

Primarily days with possible weekends/evenings/holidays (United States of America)

Pay Range

The pay range for this position is listed below. Actual pay rate dependent upon experience.

• $55,640.00 - $83,200.00
• Position Highlights
• You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The Senior Credentialing and Vendor Operations Specialist is responsible for managing the credentialing, recredentialing, and ongoing monitoring of healthcare providers and facilities for Avera Health Plans to ensure compliance with regulatory, accreditation, and organizational standards.

This role oversees vendor relationships related to credentialing and delegated credentialing functions, ensuring adherence to contract terms, performance standards, and compliance requirements, and other department vendor agreements. The position requires strong collaboration with internal stakeholders, external vendors, and regulatory bodies.

What you will do

• Manage the end-to-end credentialing and recredentialing process for providers and facilities in compliance with NCQA, CMS, state, and federal regulations. Collaborates with the Credentialing Committee to present provider files and ensure decisions are documented appropriately.
• Maintain and update credentialing policies and procedures to align with industry best practices and regulatory changes.
• Identify and implement process improvements to enhance efficiency, accuracy, and compliance in credentialing and vendor oversight.
• Oversee the provider data management process, ensuring accuracy and completeness of credentialing records in applicable systems. Coordinates the management of credentialing database extracts to downstream systems and monitors data for extensive analysis and report generation.
• Facilitate audits and surveys from regulatory and accreditation agencies, ensuring credentialing compliance.
• Manage relationships with credentialing and delegated entities, ensuring adherence to contract requirements, performance expectations, and compliance standards.
• Develop and oversee credentialing and vendor performance metrics, dashboards, queries, and conducting regular reviews and audits to ensure service quality.
• Coordinate corrective action plans with vendors as necessary to address non-compliance or performance issues.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions.

Required Education, License/Certification, or Work Experience

• Bachelor's in healthcare administration, business, health information, or a related field, or equivalent relevant work experience.
• Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) If not certified, must meet exam eligibility requirements to obtain certification within one year of hire. within 1 Year or
• Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS) If not certified, must meet exam eligibility requirements to obtain certification within one year of hire. within 1 Year
• Strong knowledge of NCQA, CMS, and state regulatory requirements for credentialing and delegation oversight.

Preferred Education, License/Certification, or Work Experience

• 4-6 years Experience in credentialing within a hospital, insurance, or managed care environment.

Expectations and Standards

• Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera's values of compassion, hospitality, and stewardship.
• Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

• Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees.
• We support you with opportunities to help live balanced, healthy lives.
• Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands-on training and mentorship