Description

As a Credentialing and Payor Enrollment Manager at Third Street, your role encompasses a range of responsibilities related to ensuring that healthcare providers are properly credentialed and enrolled with payors to facilitate reimbursement for services provided. Here's an overview of your key responsibilities:

Essential Job Duties:

• Credentialing:
  • Develop and maintain credentialing policies and procedures in compliance with federal, state, and payer regulations.
  • Coordinate the credentialing process for all healthcare providers, including physicians, nurse practitioners, physician assistants, and allied health professionals.
  • Verify licensure, certifications, education, training, and other qualifications of healthcare providers.
  • Collect and review credentialing applications and supporting documentation.
  • Conduct primary source verification of credentials through various databases and institutions.
  • Ensure timely renewal of credentials and licenses to maintain compliance.
  • Address any credentialing issues or discrepancies and work to resolve them efficiently.
• Payor Enrollment:
  • Manage the enrollment process with various payors, including Medicare, Medicaid, private insurance companies, and managed care organizations.
  • Complete and submit enrollment applications and related documents to payors.
  • Monitor the status of enrollment applications and follow up as needed to expedite the process.
  • Coordinate with billing and revenue cycle management teams to ensure accurate and timely reimbursement.
  • Stay informed about changes in payor enrollment requirements and regulations.
  • Maintain up-to-date records of payor contracts, enrollment status, and credentialing information.
• Compliance
  • Ensure compliance with Federally Qualified Health Center (FQHC), requirements, as well as regulations set forth by the Health Resources and Services Administration (HRSA), Centers for Medicare & Medicaid Services (CMS), and other regulatory/accredidation agencies.
  • Keep abreast of changes in healthcare laws, regulations, and industry standards related to credentialing and payor enrollment.
  • Collaborate with the compliance officer to conduct audits and assessments related to credentialing and enrollment processes.
    Implement corrective actions and quality improvement initiatives as needed to address compliance issues.
• Communication and Collaboration:
  • Serve as the primary point of contact for internal stakeholders, including providers, administrative staff, and leadership, regarding credentialing and payor enrollment matters.
  • Liaise with external entities, such as payors, credentialing organizations, and regulatory agencies, to facilitate communication and resolve issues.
  • Collaborate with other departments, such as human resources, finance, and legal, to ensure alignment and coordination of activities related to credentialing and enrollment.
• Supervision:
  • ???????Responsible for assessing, training, and motivating employees and job applicants. Optimize productivity within the workplace by promoting professional growth.
  • As a people manager, respond to all people-related tasks involving new talent, employee engagement and career development.
  • Hire new employees, following all applicable policies, procedures and employment law including EEOC.
  • Provide regular feedback to direct reports, documenting the feedback in the personnel file. Complete annual reviews and competencies in a timely and effective manner
  • On-boarding new team members to their role and department; providing support and guidance throughout the orientation and training period.

Requirements

Knowledge, Skills & Abilities:

• Knowledge:
  • Healthcare Regulations: Understanding of federal, state, and local regulations related to healthcare credentialing, including HIPAA, CMS requirements, and accreditation standards.
  • Credentialing Processes: Familiarity with the credentialing process for various healthcare professionals, including physicians, nurses, allied health professionals, and facilities.
  • Insurance and Payer Policies: Knowledge of insurance plans, payer enrollment requirements, and reimbursement processes, including Medicare, Medicaid, and commercial insurance.
  • Medical Terminology: Basic understanding of medical terminology and healthcare terminology relevant to credentialing and provider qualifications.
  • Quality Assurance: Understanding of quality assurance principles and practices related to credentialing, including data accuracy, compliance monitoring, and audit procedures.
• Skills:
  • Attention to Detail: Ability to meticulously review and analyze credentialing applications, documents, and databases to ensure accuracy and compliance.
  • Organizational Skills: Strong organizational skills to manage multiple tasks, deadlines, and priorities effectively in a fast-paced healthcare environment.
  • Analytical Skills: Capacity to analyze complex information, identify trends, and make data-driven decisions to improve credentialing processes and compliance outcomes.
  • Communication Skills: Excellent verbal and written communication skills to interact with healthcare providers, payers, regulatory agencies, and internal stakeholders professionally and effectively.
  • Problem-Solving Skills: Aptitude for identifying and resolving issues related to credentialing, payer enrollment, compliance, and data management efficiently and proactively.
• Abilities:
  • Attention to Detail: Ability to meticulously review and analyze credentialing applications, documents, and databases to ensure accuracy and compliance.
  • Organizational Skills: Strong organizational skills to manage multiple tasks, deadlines, and priorities effectively in a fast-paced healthcare environment.
  • Analytical Skills: Capacity to analyze complex information, identify trends, and make data-driven decisions to improve credentialing processes and compliance outcomes.
  • Communication Skills: Excellent verbal and written communication skills to interact with healthcare providers, payers, regulatory agencies, and internal stakeholders professionally and effectively.
  • Problem-Solving Skills: Aptitude for identifying and resolving issues related to credentialing, payer enrollment, compliance, and data management efficiently and proactively.
• Leadership Skills: Capacity to lead and motivate a team of credentialing staff, provide guidance, training, and support, and foster a culture of excellence and continuous improvement.
• Customer Service Orientation: Focus on delivering high-quality customer service to healthcare providers and internal stakeholders by responding promptly to inquiries, addressing concerns, and ensuring a positive experience throughout the credentialing process.Comprehensive knowledge of all available services provided at Third Street Family Health Services, community resources, interpersonal communication strategies, and computer software.

Qualifications:

• Bachelor's degree in healthcare administration, business administration, or a related field (preferred).
• Previous experience in credentialing and payor enrollment within a healthcare setting, required.
• Experience in credentialing software/database systems, preferred.

Personal Contacts:

• Frequent contact with staff of community agencies and the general public. Daily contact with agency staff. Must develop and maintain positive relationships with all of the above.

Environmental & Physical Requirements:

• Mobility: must be able to move independently and safely throughout the workplace, including offices including remote office space.
• Manual dexterity: should have sufficient hand-eye coordination and fine motor skills to perform tasks such as writing, typing, operating computer systems, and handling paperwork.
• Visual and auditory abilities: must have adequate vision and hearing abilities to effectively communicate with clients, read written materials, and interpret non-verbal cues with coworkers, vendors and external partners.
• Speech and communication: should possess clear and effective verbal communication skills to facilitate open dialogue with clients, colleagues, and other healthcare professionals.
• Sitting or standing: should be able to sustain a seated or standing position for extended periods while meeting with patients/clients/external visitors, attending meetings, or performing administrative tasks.
• Emotional resilience: must have the emotional stability and resilience to work with clients/patients/coworkers facing challenging circumstances, maintaining composure and professionalism during difficult discussions.
• Sensory sensitivity: should be sensitive to the needs of clients/patients/coworkers and exhibit appropriate responses to their physical and emotional cues, ensuring a supportive and non-judgmental environment