Payer Credentialing and Insurance Network Specialist

POSITION SUMMARY

Responsible for day-to-day Credentialing Services tasks to include payer enrollment, revalidations, and other miscellaneous tasks as required by payers; serves as initial point of contact for contracted providers, billers, insurances and other related entities. Assist with policy and procedure interpretation. BONUS: Understanding of Payer Contracting, ERISA, HMO, PPO, EPO, POS, Leased Network/Contracting Networks, Medicare and Medicaid regulations, and the medical staff privileging process.

Some travel to other system facilities.

Basic Responsibilities:

BASIC RESPONSIBILITIES:

• Work with contracted providers to meet all their credentialing service expectations outlined in their contract.
• Complete the processes to enroll and credential providers (e.g. physicians, facilities, physician assistants, nurse practitioners, etc.) with insurances while meeting payer criteria.
• Complete the processes to re-credential existing providers.
• Gather and maintain current data and documents for all providers in an organized and complete way.
• Follow up with clients and insurances for timely credentialing process(es).
• Clearly and effectively communicate with providers, Operations Managers and insurance companies handling basic questions dealing with the day-to-day operation of credentialing and enrollments.
• Review, and update, health plan directories, agencies, and other appropriate entities for current and accurate provider information.
• Knowledge of computer spreadsheets and other related applications.
• Knowledge of provider credentialing/accreditation/insurance regulations, policies, guidelines, and standards.
• Experience with or at the very least familiar with how medical claims are billed and interpret claim formatting.

OPTIONAL ADVANCED RESPONSIBILITIES:

Knowledge of similarities and differences in Reimbursement methodologies across hospitals, RHC’s and group practices.

Payor’s Market Share

Utilization Management

Strategic considerations involved in the payor negotiating strategy.

Appeal procedures for denied claims.

Understand Financial data for various healthcare providers to determine if Payers are meeting key performance indicators and abiding to contract terms.

REQUIRED QUALIFICATIONS:

High school degree or equivalent required. Associates degree in business, healthcare related field preferred or equivalent experience. Experience in credentialing, privileging or other medical experience relevant to insurance carrier credentialing, re-credentialing and follow up preferred.

• High level of awareness of pertinent details; excellent organizational skills.
• Strong analytic and problem-solving abilities.
• Excellent verbal and written communication skills.
• Effective and efficient oral and written communication skills.
• Must handle pressure effectively.
• Able to maintain confidentiality.
• Excellent computer literacy and skills with the ability to use PC software (Microsoft Office-Excel, Word, PowerPoint) with the ability to master programs needed for position.
• Must be able to work independently.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• AD&D insurance
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person