Associate II - HealthPlan (Claim Adjudication)
UST Global · Chennai · onsite · Posted 65d ago
Undisclosed6–11 yrsfulltimeSourced from
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About this role
Job Summary
Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.
The Provider Recredentialing Specialist is responsible for managing the end-to-end recredentialing lifecycle for healthcare providers to ensure compliance with payer, regulatory, and accreditation requirements. The role focuses on periodic validation of provider credentials, documentation updates, and ongoing monitoring to maintain an accurate and compliant provider network. Recredentialing is a cyclical process that ensures providers continue to meet required standards through updated verification and monitoring activities. Shift Time: 5:30pm to 2:30am IST.
Key Responsibilities - Recredentialing Lifecycle Management: Manage end-to-end provider recredentialing processes in line with payer and regulatory timelines. Initiate recredentialing cases based on due dates, expirable, and renewal triggers. Track and manage provider credential expirations (licenses, certifications, malpractice insurance).
- Documentation Application Review: Collect and review recredentialing applications via systems like CAQH or internal platforms. Validate completeness and accuracy of provider documentation. Follow up with providers for missing or inconsistent information.
- Primary Source Verification (PSV): Perform PSV for: Licensure, Board certification, Education training, Work history. Validate data from authoritative sources (State Boards, NPPES, OIG, NPDB, etc.). Ensure compliance with regulatory and payer requirements.
- Background Compliance Checks: Conduct sanction and exclusion checks (OIG, NPDB, Medicare/Medicaid). Identify discrepancies, red flags, or compliance risks. Escalate issues for further clinical or committee review.
- Provider Data Validation Quality Checks: Ensure accuracy of provider profile (specialty, affiliations, demographics, practice locations). Perform quality audits on completed credentialing files. Maintain documentation integrity for audit readiness.
- Workflow Management: Productivity: Manage assigned inventory/queue ensuring SLA/TAT adherence. Maintain productivity and quality benchmarks (first-time-right processing). Support backlog clearance and aging reduction initiatives.
- Stakeholder Coordination: Interact with providers, internal teams, and external verification agencies. Support escalations and provide status updates to clients/stakeholders. Collaborate with QA, compliance, and operations teams.
- Reporting Governance: Update dashboards and trackers for recredentialing status and closures. Highlight risks related to expirable, delays, or compliance gaps. Support audit readiness and regulatory reviews.
3-6+ years in Provider Credentialing/Recredentialing (BPO/US Healthcare)
Education Bachelor's degree (Healthcare/Admin/Business preferred)
KPIs / Performance Metrics - Recredentialing TAT adherence
- PSV accuracy
- Compliance score
- Documentation quality / audit pass rate
- Queue management (aging, backlog reduction)
- Ensures regulatory compliance and reduces audit risk
- Improves provider network accuracy and reliability
- Minimizes claim denials due to credentialing gaps
- Enhances provider onboarding continuity and payer alignment
Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.
Sourced from naukri
Skills
credentialingRFPworkflow managementMonitoringUS HealthcareRegulatory CompliancebpoanalyticalData ValidationQuality Audit
About UST
UST Global
IT Services & Consulting
14.0k+
employees
1999
27 years old
Aliso Viejo, California
US
₹12.9L PA avg
Avg at UST
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UST helps the world's best organizations succeed through digital transformation, crafting disruptive solutions and strategies bringing our clients vision to life.
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IT Services & ConsultingManufacturing
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