Associate II - HealthPlan (Claim Adjudication)

Job Details

• Location: Chennai, Trivandrum
• Experience: 2 - 3 Years
• Job Type: Full Time
• Openings: 10

Role Description

Job Description – Provider Recredentialing Specialist Shift Time : 5:30pm to 2:30am IST Role Summary 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. Key Responsibilities 1. 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) 2. 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 3. 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 4. 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 5. 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 6. 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 7. 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 8. 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 Skills & Competencies Strong knowledge of: Provider Credentialing & Recredentialing lifecycle PSV (Primary Source Verification) CAQH, NPPES, NPDB, OIG processes Understanding of US healthcare payer operations High attention to detail and documentation accuracy Analytical & problem-solving mindset Strong communication (provider outreach, escalations) Ability to work with high-volume operations and SLAs Experience & Qualification Experience: 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) Value Add (for BPO Portfolio / RFP positioning) 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

Skills

<p>Provider Credentialing, NPPES, NPDB, Healthcare Systems</p>