Credentialing Regulatory and Compliance Specialist

Minneapolis, Minnesota
Jul 04, 2018
Jul 25, 2018
Employment Status
Full Time

Health Care that Starts with You!

Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.




At UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.



Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do.




Position Description

This position is responsible to investigate and primary source verify the credentialing and re-credentialing applications in accordance to NCQA, CMS and MDH Standards for all contracted providers.  Provide verbal and written communication to contracted providers to obtain compliant documents and approval dates.  Prioritize and organize work in order to meet regulatory requirements.  Conduct audits on applications processed prior to credentialing approval per NCQA, MDH and CMS requirements.  Primary liaison for external audits. Specific duties and responsibilities include:  

Audit the integrity of credentialing data entered into the credentialing database by analyzing audit reports and working with staff to ensure adherence of regulatory guidelines and accuracy of information.

Train Credentialing Staff to ensure adherence of regulatory guidelines of the credentialing and delegated processes.

Assist in developing, implementing and maintaining credentialing policies, procedures and work instructions. 

Perform credentialing investigation and primary source verification for provider initial and re-credentialing of assigned providers utilizing NCQA Standards and other federal and state regulatory requirements.  Ensure timely verification to prevent any negative impact related to compliance or regulatory requirements. 

Maintain timely communication with external providers regarding the eligibility and credentialing decisions and/or related provider issues.

Serve as resource specialist for internal departments for daily issues related to provider credentialing activities.

Identify administrative and professional issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up with provider, manager and cross-departments. 

Prepare credentialing file reports, work with directly with Medical Directors, and present credentialing files and peer review to the Credentialing Committee for approval. 

Enter and maintain credentialing data following NCQA as well as state and federal requirements.

Maintain timely communication with supervisor and associate director regarding Credentialing Compliance 360 emails.

Prepare Credentialing Committee materials, schedule prep meetings, email notifications to committee and complete post meeting minutes.

Other projects and duties as assigned. 


High school diploma or equivalent.  Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator Certification required.

Required Experience

Two years of relevant experience in health care related field. PC experience including spreadsheet and word processing; preferably Microsoft Access, Excel and Word.  Credentialing/re-credentialing experience. 

Preferred Experience

Experience in a clinic business office, insurance or HMO environment. Delegation of credentialing/re-credentialing experience. Experience working with AMISYS or similar claims application. Previous supervisory or training experiences a plus.



UCare is proud to be a recognized Star Tribune Top Workplace for the 9th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply.


As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.


Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers. At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.

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