The Managed Care Credentialing Coordinator is responsible for performing credentials verification for Children's Health employed and contracted practitioners in compliance with standards set forth by NCQA, CMS, and contracted payors. This position is responsible for submitting accurate and complete provider enrollment applications, following up with payer credentialing departments and provider enrollment representatives to ensure providers are fully credentialed and loaded as participating with all applicable contracted health plans. Managed Care Credentialing Coordinators are accountable for maintaining and disseminating accurate plan participation status reports and billing information to all applicable Children’s Health internal departments to maximize collections in the revenue cycle management process.
JOB SPECIFIC RESPONSIBILITIES:
- Prepare credentialing files for individual and organizational providers per NCQA, CMS, and contracted payor standards. Perform primary source verification using pre-approved sources, documenting verification efforts consistent with Children’s Health Provider Credentialing policies. Present files to Credentialing Manager for review and auditing prior to Credentials Committee meetings, highlighting red-flags for peer review and discussion.
- Obtain, verify, and maintain complete and accurate demographic information and required licensure/ certification documentation for supported individual practitioners and organizational providers. Collaborate with multiple departments to obtain and retain current copies of certificates, etc. Maintain the accuracy of the credentialing database. Maintain the accuracy of provider CAQH profiles and re-attest every 120 days.
- Manage the enrollment process for government plans, Medicaid Managed Care plans, and commercial plans for supported individual and organizational providers. Coordinate the gathering and verification of necessary data, working directly with practitioners or appropriate representatives. Complete applications accurately and thoroughly, meeting standards set forth by CMS, HHSC, and commercial payors. Obtain application signatures from the authorized signatory and provide all required supporting documentation. Submit applications and follow up diligently to ensure timely processing. Respond to deficiency notifications in a timely manner. Follow up diligently on provider addition requests and communicate provider changes, corrections, and terminations.
- Create, maintain, and disseminate plan participation status and billing information to all applicable Children’s Health internal departments and 3rd party billing agencies (as applicable) to maximize collections in the revenue cycle management process.
- Complete a quarterly roster reconciliation process for all supported practitioners with applicable health plans. Verify accuracy and communicate additions, changes, and corrections in a timely manner, along with necessary Support Patient Financial Services and other Children’s Health billing departments by addressing concerns regarding claim rejections/denials in a timely manner, resolving provider enrollment issues. Participate in special claim projects, coordinating with Provider Relations/Network Management as needed.
- Maintain positive working relationships with payer representatives, providers, and all Children’s Health internal departments.
SPECIFIC KNOWLEDGE, SKILLS, AND ABILITIES:
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
LICENSES and CERTIFICATIONS:
Certification as a Certified Provider Credentialing Specialist (CPCS), preferred.
Certification as a Certified Professional Medical Staff Management (CPMSM), preferred.
- Minimum of 2 (two) years of experience in Payor Relations or Credentialing with an insurance company, hospital, or other large group of providers, required.
Two-year Associate's degree or equivalent experience, required.
Four-year Bachelor's degree or equivalent experience , preferred.
Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time. cb#