Provider Credentialing Specialist

Position Title: Credentialing Specialist

Reports To: Revenue Cycle Manager Classification: Hourly

Attendance at HIPAA and compliance educational programs is a requirement of employment.

SUMMARY:

The person in this position is responsible for all aspects of the provider credentialing and insurance plan participation/enrollment for providers that submit claims to insurance payers. The scope of providers includes Primary Care, Behavioral Health/Social Services, Eye, Dental and Vision. The Credentialing Specialist will report to the Revenue Cycle Manager.

DUTIES AND RESPONSIBILITIES:

l. Coordinates the collection and completion of all insurance enrollment paperwork.

2. Works with Human Resources and Providers to obtain documents and/or information required to efficiently complete the enrollment process.

3. Initiate, follow and complete all provider enrollment with payers to ensure minimum impact on completed claims or billing delays.

4. Tracks the enrollment process with the insurance plans and addresses any identified issues with the providers and/or plans.

5. Organize and maintain accessible electronic and paper files of documentation, applications, and resulting contracts.

6. Maintain provider information in CAQH and other systems as needed.

7. Maximize use of technology to automate processes.

8. Tracks the status of all insurance agreement/contracts and facilitates the update and completion of the agreement/contracts as needed.

9. Ensures all data elements are collected from providers during initial on-boarding as well as during re-enrollment/re-credentialing process.

10. Tracks all credentialing activities, including insurance enrollment, state licenses, DEA, professional liability, and re-credentialing and provide long-term recommendations for systematic changes as needed.

11. Provides regular status reports and timely appropriate escalation of issues of both provider insurance enrollment/participation, credentialing and insurance agreement/s contracts.

12. Follow up with contacts at insurance plans and hospitals to address any issues.

13. Facilitates updates to insurance agreements/contracts including amendments/ addendums.

14. Completes Primary Source Verification, Education, Training, State License, DEA, Medicaid/Medicare Sanctions.

15. Secure copies of malpractice claims history.

16. Serve as liaison to IT to assure that providers are set up accurately in the Electronic Medical Record system so that claims can be processed accurately and in a timely fashion.

17. Back-up to payment posting, billing and AR functions.

18. Perform other duties as required by the position or as assigned by supervisor. This job description is not designed to cover or contain a comprehensive listing of all the activities, duties and/or responsibilities that are required of this position. Duties and responsibilities are subject to change due to business needs at any time with or without previous notice.

MINIMUM JOB REQUIREMENTS:

· Minimum of a High School diploma or its equivalent (GED). Associate's, Bachelor's degree in business administration or healthcare administration is preferred.

· Minimum of two (2) years of relevant credentialing and provider insurance enrollment experience.

· Certification/Licensure: CPCS (Certified Provider Credentialing Specialist) preferred.

· Ability to maintain confidentiality of all provider information, including appropriate disposal of confidential documents is required.

· Experience in culturally diverse settings and passionate about community health services.

· Strong interpersonal, organizational and communication skills including both written and verbal.

· Ability to meet deadlines and work comfortably in fast-paced work environment, independently and as part of a team.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

1. Ability to recognize areas for improving and problem solving.

2. Experience using PECOS, CAQH, Ohio Medicaid Website, and various insurance canier websites.

3. Ability to attend to multiple tasks at the same time. Ability to prioritize assignments and responsibilities to ensure compliance with established deadlines and protocols.

4. Excellent phone and communication skills.

5. Strong organizational and follow-up abilities.

6. Advanced working knowledge of computer program including all Microsoft Office programs and the ability to trouble shoot and train in those areas.

7. Effective oral and written communication skills.

8. Ability to work with persons from a wide diversity of social, ethnic and economic backgrounds, and maintain a professional attitude in stressful situations.

9. Ability to take initiative, ask questions, and work independently.

10. Ability to utilize telephones, computer terminals, fax machines, and copiers is required.

11. Persistent tracking and follow-up with payers to ensure applications have not been lost or delayed due to incomplete information.

12. Perform other duties assigned by the CFO.

13. Must have reliable transportation.

CONDITIONS OF EMPLOYMENT:

Must be willing to submit to post offer, pre-employment physical examination/medical history check if requested.

• May be required to submit to TB and HEP-B screening.

• A pre-employment background investigation and drug screen is required.

WORKING CONDITIONS AND PHYSICAL EFFORT:

Prolonged sitting or standing may be required. Those physical movements and the degree of mobility, manual dexterity and hand-eye coordination normally associated with administrative duties in a health center office setting will be performed on a repetitive basis. This also includes bending, twisting, reaching, lifting, pulling, pushing, and walking. The ability to sustain moderate physical activity, handling of average-weight objects up to 25 pounds, and standing and/or walking for more than four (4) hours per day is expected. Working under stressful conditions as well as irregular hours may be required.

Job Type: Full-time

Pay: $19.00 - $20.00 per hour

Expected hours: 40 per week

Benefits:

• AD&D insurance
• Dental insurance
• Employee assistance program
• Employee discount
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Education:

• Associate (Preferred)

Experience:

• Credentialing: 1 year (Preferred)

License/Certification:

• Certified Provider Credentialing Specialist (Required)

Work Location: In person

Salary : $19 - $20