Provider & Payer Services Credentialing Specialist

Join a team that delivers excellence.

Lehigh Valley Health Network (LVHN) is home to nearly 23,000 colleagues who make up our talented, vibrant and diverse workforce.

Join our team and experience firsthand what it's like to be part of a health care organization that's nationally recognized, forward–thinking and offers plenty of opportunity to do great work.

Imagine a career at one of the nation's most advanced health networks.

Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward–thinking organization offering plenty of opportunity to do great work.

LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital – Cedar Crest, Lehigh Valley Hospital – Muhlenberg, Lehigh Valley Hospital– Hazleton, and Lehigh Valley Hospital – Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day.

Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Serves as the Subject Matter Expert (SME) to internal and external stakeholders and maintains positive relationships with contracted payers to ensure successful credentialing. Works collaboratively with LVPG Operations and Revenue Cycle to ensure accuracy and resolves issues to allow for continued streams of revenue. Participates in all aspects of the LVPHO and / or LVPG Delegated Credentialing Agreements (DCA) including discovery phase, pre–audit, contract negotiations, and successful implementation. Ensures accuracy of credentialing policies per NCQA standards, CMS and State Medicaid regulations, and DCA requirements.

Job Duties

• Manages the DCA discovery phase and implementation process for new LVPHO and / or LVPG DCA opportunities. Participates in scheduling, attending, and successfully completing new LVPHO and / or LVPG DCA pre–audits as required by NCQA standards, CMS. and State Medicaid regulations. Participates in DCA contract negotiations with new potential LVPHO and / or LVPG delegated payers. Works with LVHN Medical Staff Services and delegated payer to schedule, attend, and finalize all required audits for both LVPHO and LVPG delegated payers. Coordinates ongoing collaboration with delegated payers specific to all applicable updates necessary to credentialing policies and credentialing processes and procedures based upon NCQA standards, CMS, and State Medicaid regulations.
• Screens all incoming credentialing / re–credentialing packets and contracts for completeness and accuracy. Works collaboratively with Provider Services Representative to ensure accurate data entry. Collaborates with Provider and Payer Account Coordinator with delegated and non–delegated rosters to ensure accuracy of payer reporting. Works collaboratively with LVPG Operations and LVPG Revenue Cycle to ensure data accuracy and integrity while maintaining a focused mindset on maximizing revenue and minimizing losses. Enrolls LVPHO Value Based Risk (VBR) / Accountable Care Arrangements (ACA) which results in additional revenue stream for LVPHO and participating providers including LVPGs.
• Acts as primary point of contact for LVHN Medical Staff Services for initial credential, provisional re–credential, and biennial re–credential requests for primary source verifications (PSVs). Determines which PSVs would be applicable based upon LVHN Medical Staff Services request. Completes all PSV requests within required timeframes and maintains open communication with LVHN Medical Staff Services. Collaborates with LVHN Medical Staff Services to appropriately meet all payer and regulatory audit requirements.
• Maintains accuracy of all credentialing policies ensuring updates required by NCQA standards or CMS and State Medicaid regulations are made in a timely fashion. Manages ongoing monthly monitoring (OIG, SAM, Medicare Opt Out, and PA Sanctions) as required by NCQA Standards and supplies any applicable findings to leadership for further review. Utilizes knowledge of NCQA standards, CMS, and State Medicaid regulations to research and implement any new PSV requirements as necessary and within required implementation timeframe. Ensures contract compliance for all aspects of delegated credentialing. Guarantees all provider files are CMS, DOH, and NCQA complaint for payer and regulatory audits.
• Acts as primary contact for providers requesting participation with Valley Preferred Regional Network inclusive of initial credentialing packet and presentation to LVPHO Credentials Committee. Assumes direct responsibility for initiating, creating random file selection, performing and finalizing required annual audits for the Valley Preferred Regional Network. Performs annual audits of Valley Preferred Regional Network hospitals and providers to evaluate and approve for continued participation.

Minimum Qualifications

Preferred Qualifications

Physical Demands

Lift and carry 7 lbs., continuous sitting >

67%, frequent keyboard use / repetitive motion, frequent fine motor activity / wrist position deviation.

Job Description Disclaimer : This position description provides the major duties / responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adh...