Sr. Provider Enrollment & Credentialing Coordinator

Position Summary

The Provider Enrollment Group (PEG) is the central ColumbiaDoctors unit responsible for payer credentialing and enrollment services. The Senior Provider Enrollment & Credentialing Coordinator performs analytical provider enrollment and credentialing functions with payers, vendors, and practices

Responsibilities

Technical

• Prepares, submits, and tracks payer enrollment and credentialing material submissions. Identifies variances, issues, and delays, addressing them in a timely manner, escalating with internal and external stakeholders and management as needed.
• Performs ongoing outreach and follow-up with providers, payers, and vendors, ensuring that contractual obligations in terms of turnaround timeframes, credentialing and loading requirements are met, escalating when deficiencies are identified.
• Audits materials returned by providers, payers, and vendors for accuracy and completeness, addressing variances in a standardized way according to well-defined standard operating procedures.
• Prepares and distributes status updates to stakeholders for accurate and timely updating of internal and external platforms (including but not limited to databases, credentialing grids, dictionaries, portals, and websites).
• Serves as a key contributor to special credentialing, enrollment, and operational projects, including large-scale initiatives and centralization of additional services and functions.
• Performs compliance checks and quality assurance activities to maintain the integrity of data and ensure adherence to standard operating procedures. Proficient in excel to utilize v-lookup, pivot tables, concatenation, and other reporting tools to validate data from multiple sources.
• Serves as the primary point of contact for providers, payers, and vendors. Leads regular meetings to discuss the status of open items and deliverables, preparing agenda in advance, and following up with meeting minutes. Escalates to internal and external stakeholders as needed.
• Troubleshoots credentialing associated denials/underpayments, collaborating with stakeholders to complete a comprehensive root-cause analysis, following through to resolution to minimize adverse impact to revenue and patient/provider abrasion.
• Identifies trends impacting multiple providers, payers, and/or groups. Prepares and distributes status reports, making recommendations for next steps and escalating to internal and external stakeholders.
• Performs scheduled and ad-hoc audits of payer and vendor data ensuring updates are made in credentialing database and discrepancies are addressed with external parties.
• Administers credentialing processes in accordance with NCQA guidelines, including quality assurance and compliance tasks, delegated credentialing payer audits/reporting, and coordination of Credentialing Committee processes.
• Collaborates on cross-functional projects, delegating tasks as deemed appropriate, asking for guidance when required, and provides cross-coverage for a wide range of related responsibilities.
• Establish and maintain positive relationships with payers, providers, practices, and administration, providing subject matter expertise and tailoring communications to adapt to each audience.
• Effectively communicates through informal and formal presentations for various audiences to ensure relevant communication is cascaded to the various interest and stakeholder groups as needed.

Strategy

• Works collaboratively with fellow team members to regularly evaluate the effectiveness of department Standard Operating Procedures and workflows and identify gaps. Provides feedback and recommendations to supervisor for improvements. Implements approved changes.

People

• Mentors others in individual and team accountability, modeling behavior and demonstrating best practices/techniques.

Other

• Performs other related duties as assigned within the scope of practice.
• Maintain familiarity and stay current with NCQA requirements and health insurance plan procedures.
• Represents PEG on committees, task forces, and workgroups as assigned.
• Conforms to all applicable HIPAA, Billing Compliance, and safety policies and guidelines

Minimum Requirements

• Bachelor’s degree or equivalent in education and experience.
• A minimum of 3 years of related experience.
• An equivalent combination of education and experience may be considered.
• Must demonstrate advanced analytical and problem-solving skills with attention to detail and accuracy.
• Advanced time management skills including planning, organization, multitasking, and ability to prioritize required.
• Must demonstrate effective communication skills both verbally and written.
• Specialized knowledge of managed care Credentialing/Enrollment.
• Intermediate knowledge of Microsoft Excel (e.g. vlookup, pivot tables, etc.) or similar software is required.
• Must be a motivated individual with a positive and exceptional work ethic.
• Must successfully complete systems training requirements.
• Ability to work collaboratively with a culturally diverse staff and patient/family population, strong customer service skills, demonstrating tact and sensitivity in stressful situations.

Preferred Qualifications

• NAMSS Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) preferred.
• Prior experience with IntelliCred, Cactus, or similar credentialing systems is preferred.
• Prior experience at an academic medical center or health insurance plan is preferred.