Part-time Credentialing Specialist

JOB DESCRIPTION

Under the supervision of the Front Desk & Credentialing Manager, the PT Credentialing Specialist is primarily responsible for administering the Credentialing process for the organization. Works independently to coordinate, develop, monitor and maintain the credentialing process. The PT Credentialing Specialist coordinates provider relationships with Medicaid HMOs and other private insurance companies to increase third party revenue. Also, performs necessary tracking results and reconciliation for capitation payments and provider credentialing.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

• Responsible for implementation and oversight of all physician credentialing and re-credentialing activities.
• Responsible for managing compliance requirements for delegation agreements.
• Responsible for the development of Credentialing policies and procedures.
• Maintains knowledge of HRSA, NCQA, and Joint Commission credentialing requirements.
• Coordinates and manages the dissemination to health plans and other payers.
• Monitors regulatory sources to stay informed of rapidly changing rules and regulations related to credentialing processes.
• Reviews and processes all provider applications.
• Analyzes and resolves provider file issues, tracks progress on network management, and produces weekly reports.
• Reviews and analyzes provider file changes.
• Works with Managed Care and Hospital credentialing coordinators
• Responds to provider inquiries received by letter, phone, or internal departments.
• Administers Re-credentialing of network providers.
• Reviews and monitors provider complaints and grievance files.
• Provides oversight of managed care or other payer contracts.
• Administrative Meeting issues as required. Credentialing Committee, Medical Leadership Meetings and to assist with others as needed.
• Ability to apply common sense understanding to carry out moderately complex, multi-step instructions and make appropriate independent decisions as necessary
• Maintains close contact with Billing Department to provide updates on new hires, terminations, approvals from MCOs, and any other information the billing department could need from credentialing.
• Serves as liaison between the CEO, Senior Executive Leadership team, managers of each department, and Staff, Insurance companies, Providers, and Human Resources to ensure current provider licenses and provider agreements. As well as keep Billing updated on any changes for billing purposes.
• Negotiates discount rates for quick return of payment for billed non-contracted payer sources.
• Responsible for handling the credentialing process for Medicaid HMOs with the assistance of Human Resources and the Chief of Medical.
• Responsible for handling and tracking insurance discrepancies pertaining to enrollment.
• Maintains and updates the provider's CAQH files.
• Maintains and updates the provider’s eClincialWorks profiles.
• Responsible for assisting with access to various insurance verification systems
• Other duties as assigned.

QUALIFICATIONS

• Bachelor's degree preferred or at least three to five years experience
• Requires Experience with database reporting and proficiency with word processing and spreadsheet software.
• Experience required in this or similar role for a minimum of 3 years as well as effective verbal and written communication skills to communicate with providers, Manage Care Companies, and hospital personnel via phone, email, and through prepared correspondence.
• At least three years of experience with the EMR or other FQHC system.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED

• Minimum five years of healthcare insurance experience to include Medicaid (District of Columbia & Maryland), Medicare, HMOs, and private insurance.
• Creativity, flexibility, and vision-oriented.
• Ability to work independently in a team-oriented environment and interact well with individuals with diverse ethnic and cultural backgrounds and needs.
• Superior oral and written communication skills.
• History of positive customer relations as demonstrated by supervisor recommendation.
• Ability to perform presentations and interact with many different levels of UHC leadership.
• Familiar with medical billing and collection procedures to include Medicaid, Medicare, private insurance, and self-pay.
• Working knowledge of eCW or other patient management systems.
• Ability to work independently with minimum supervision.
• Excellent computer skills, including Excel, Microsoft Word, etc.