Credentialing and Payer Enrollment Specialist

OakLeaf Medical Network Mission and Vision:

Mission: Since 1994 OakLeaf Medical Network has been committed to delivering the highest quality care, growing independent medicine, and promoting accessible value-added health care services.

Vision: OakLeaf Medical Network is committed to the continuous delivery of innovative, personalized, compassionate care in the Chippewa Valley for years to come.

ABOUT US: OakLeaf Medical Network is an Independent Physician Association (IPA) and Clinically Integrated Network (CIN) serving independent physician and non-physician provider practices in Eau Claire and the greater Chippewa Valley. To support the mission of OakLeaf Medical Network, we offer a comprehensive solution for Healthcare Payer Contracting, Credentialing, and Business Office Support. We provide delegated credentialing for over 20 payers, 380 providers and 27 independent practices.

JOB SUMMARY: The Credentialing and Payer Enrollment Specialist provides critical support to Independent Medical Practices within the OakLeaf Medical Network. This person supports all aspects of the payer enrollment process providing oversight and management of all related activities including confidential provider database administration, delegated credentialing enrollment activities to include roster management and reporting, ongoing monitoring of directory information for practices, and payer claims assistance for providers. This position also supports the reimbursement contract renewal lifecycle and actively takes charge of problems or projects working directly with all Healthcare Payers and or Independent Medical Practices.

Essential Functions

· Maintain confidential enrollment files in electronic credentialing database.

· Review credentialing files for accuracy and completeness.

· Monitor status of payer credentialing applications and perform follow-up as necessary.

· Assist with development of provider rosters to comply with various contracting services and requirements.

· Prepare and submit credentialing applications to payers on behalf of providers.

· Administer and oversee new and renewed enrollment processes for providers to ensure proper claim payment.

· Monitor and assist further investigations as deemed necessary by intervening to ensure that providers receive prompt and accurate reimbursement.

· Assist with development and completion of all quarterly and annual reports.

· Communicate payment, policy, or procedural information from the payors to member clinics.

· Facilitate the timely enrollment of new clinics and new providers.

· Serve as liaison between OLMN clinics and payer representatives to resolve all provider enrollment and payment-related issues.

· Initiate, receive, and resolve questions pertaining to enrollment and contract payment via phone and written correspondence.

· Special projects, as needed.

Qualifications

Education

· High school graduate or GED equivalent.

· Bachelor's Degree preferred, preferably in Health or Business-related field, or a related combo of work and school.

Prior Related Experience

· A minimum of 2 years in health care with exposure to credentialing and payer enrollment processes.

Eligibility

· The candidate must not have been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory or licensing agency.

Knowledge, Skills and Abilities

· Effective and strong oral and written communication skills.

· A high degree of proficiency with Microsoft Office, including Excel, is a must.

· Ability to meet scheduled deadlines with minimal supervision.

· Ability to maintain professional demeanor and strict confidentiality of provider and company information.

· Maintain knowledge of NCQA, CMS, State and Federal regulations related to credentialing activities.

· Ability to multi-task, deal with complexity frequently, and have a strong tolerance for adaptability.

· Must be results-focused with the ability to effectively organize work, prioritize projects, and manage time.

· Rigorous attention to detail, data integrity, and accuracy is imperative.

· Exercise strong judgment to analyze and interpret guidelines; assess, evaluate, and solve problems; and make recommendations for handling specific situations and creating more efficient workflows.

· A willingness to provide highly professional customer service, including a positive mental attitude, a willingness to collaborate, inherent resourcefulness and drive, and an ability to work independently is critical.

· Ability to work with a variety of people and circumstances.