Credentialing Specialist—Hammond, LA

Definition and Role

The position of Credentialing Specialist  will report directly to the Director of Contracting and Credentialing and is based at the home office. This role involves and supports the enterprise wound medicine service line through the evaluation, planning, implementation and tracking of administrative, regulatory, and clinical processes, policies, and procedures.  This role working closely with related department heads to ensure pull through. Additional service lines may be assigned based on MedCentris strategic initiatives.

Job Responsibilities and Duties

• Processing and filing reports, confirming provider's information with accrediting and licensing agencies
• Responsible for keeping Modio (credentialing database) up to date for providers and facilities, i.e., uploading copies of all current provider regulatory documents, credentialing forms, approvals, etc.
• Responsible for clearly documenting the status of provider applications, licenses, or any pertinent information we may handle in Modio.
• Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed
• Maintains copies of all current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
• Maintains knowledge of credentialing guidelines for contracted Health Plans.
• Maintains knowledge of credentialing guidelines for Hospital privileges.
• Responsible for completing CAQH attestations every 90 days.
• Submits demographic updates to health plans, licensing agencies, and other entities in compliance with their time frame for updates as well as following up through completion of the update(s), including but not limited to reviewing and updating the Provider Directory, Health Plan specific rosters or demographic change forms, etc.
• Provides credentialing and privileging verification.
• Monitoring and responding to inquiries received in the credentialing email throughout the day.
• Respects and maintains provider confidentiality in written, verbal and electronic information.
• Sets up and maintains provider information in online regulatory and credentialing databases and systems, i.e., CAQH, PECOS, etc.
• Reviews Modio Alert Reports daily to ensure timely renewals of provider licenses, professional liability insurance, certification expirations, credentialing expirations, etc.
• Processing annual regulatory renewals, i.e., Malpractice Insurance, Licensure, etc.
• Assists in developing documents such as policies, protocols, and procedures for approval.
  
• Ensures appropriate government credentialing regulations are maintained and staff are properly enrolled with insurance agencies.
• Renewal of providers Board Certifications and memberships per directives of established provider
• Setup / Maintenance of Providers in NextGen / MediTouch.
• Assist in the oversight of credentialing new and established health care providers for both insurance and facilities, and maintenance of information to include assisting client facilities with primary source verification, follow up, data collection, data entry, and document review.
• Researches and stays abreast of Federal, State, accreditation, and practice regulations.  Provides summaries of research including impact to clinical, operational, and business considerations to Director of Contracting and Credentialing.
  
• Assists in ensuring effective plans are in place and works proactively with other departments including but not limited to IT, HR, intake, billing, administration, providers, sales, and Executive Leadership, in accordance with applicable project goals, company standard operational procedures (SOPs), and regulatory requirements.
• Onboarding and Offboarding of new providers
• Assist in training of new employees
• Provider Hospital / Reappointments for Hospitals & Facilities
• Adding and/or updating providers and facilities in PECOS
• Peer / Professional reviews / references
• Utilizes all available communication mechanisms while facilitating the collaboration of services among all team members in order to troubleshoot field issues and concerns.
• Ensures potential roadblocks and risks are escalated to the attention of leadership when appropriate.
• Maintain relationships with providers, and administrative staff, and always works collaboratively with other regional and/or service line leaders.
• Facilitating meetings as needed to provide updates to leadership and other departments
  
• Assist with claim denials as it relates to a credentialing issue.
• Reports as requested by leadership, i.e., Nuclear Response Report
• Any and all other duties as assigned
  

Qualifications and Skills

• 3 + years of credentialing experience
• Must have excellent communication, analytical, critical thinking, and writing skills.
• Experience in project management.
• Experience with start-up and close-out activities.
• Ability to organize and prioritize work and manage multiple priorities.
• Excellent verbal and written communication skills, excellent attention to detail.
• Ability to research and analyze data and work independently with minimal supervision.
• Ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.
• Proficient use of Microsoft Office applications (i.e., Word, Excel, Power Point, Project) and internet resources.
• Knowledge of PECOS and CAQH preferred. Knowledge and understanding of NPI, Medicare, and Medicaid preferred.

Physical Requirements

• Mobility and Lifting: Frequent sitting for extended periods of time; frequent standing; frequent lifting up to 25 pounds.
• Visual: Constant ability to read information, including close-up; constant ability to use a computer screen; frequent use of good overall vision, including color perception.
• Dexterity: Constant eye and hand coordination and manual dexterity to write, operate a computer keyboard and finely manipulate small objects.
• Emotional/Psychological: Constant ability to make decisions and concentrate.