Description:

The Credentialing Specialist/Coordinator is responsible for maintaining active status for all providers by successfully completing initial and subsequent Re‐Appointment and Re‐Credentialing packages as required by the Health Center and for our admitting hospital (UMass), our commercial payers, Medicare and Medicaid.

Responsibilities:

Provider OnBoarding (Privileging/Credentialing)

• Initial Contact/Support to Provider’s with Privileging & Credentialing process at acceptance of employment
• Initiate Provider Hospital Credentialing for Physicians, collaborate w/UMass to maintain Physician Hospital Appointments
• Maintain internal provider ID’’s roster to ensure all information for Provider’s is accurate and logins is available (NPI/PECOS access)
• Complete/Provide support to providers in Applying for and renewing provider licenses; Professional, DEA, Controlled Substance, and any other required supporting documentation to practice medicine.
• Perform all Primary Source Verifications as required by CMS/HRSA/Joint Commission/NCQA for all Health Care Professionals at initial and Re‐Appointments of all LIP’s.
• Facilitate/Support providers in signing up and/or obtaining compliance trainings, CME’s, Life Support Trainings when due
• Re‐Credential providers as required for both the Health Center and for UMass
• Board‐Provider List
• Board Letters

Credentialing Compliance:

• Maintain accurate provider credentialing profiles in (Cactus) Cred software.
• Track and Report Monthly on all Credentialing Expirables

Provider Health Plan Enrollment (Revenue Cycle):

 Complete revalidation requests issued by both MassHealth and PECOS for all providers.

• Complete credentialing applications to enroll providers to commercial payers, Medicare, and Medicaid
• Track/Report Provider enrollment progress 
• Initiate and Maintain each provider’s CAQH database file timely and according to the schedule published by CMS
• Complete re‐credentialing applications for commercial payers
• Work closely with the Revenue Cycle Director and billing staff to identify and resolve any denials or authorization issues related to provider credentialing 
• Create/Maintain accurate provider profiles on online profiles in CAQH, PECOS, NPPES, MassHealth/C3 and CMS databases
• Other duties as assigned

 Knowledge, Skills and Abilities:

• Knowledge of provider Credentialing & Provider Enrollment and its direct impact on the practice’s revenue cycle
• Excellent computer skills including Excel, Word, and Internet navigation for State, Federal sites and healthplan searches
• Detail oriented with above average organizational skills, and time management
• Plans and prioritizes to meet deadlines
• Excellent customer service skills; communicates clearly, effectively and professionally

Education and Experience:

• High School Diploma, GED, Associates /Bachelors degree
• 2 years credentialing experience preferred
• 2 years experience in a medical practice business office role required