Coordinator, Credentialing

Summit Health•Bend, OR

About The Position

The Credentialing Coordinator will be responsible for administering the provider and facility enrollment process; oversees and coordinates both the initial and reappointment credentialing applications process; assess and validate practitioner qualifications as required by regulation and SMG policy. Position is responsible for processing and maintaining staff applications for all physicians and mid-level providers. Assist in the development and update of all policies and procedures pertaining to credentialing. Serves as credentialing liaison for contracted health plans and hospitals and activities related to delegated credentialing contracts. Support Revenue Cycle team by assisting in claim management, denial management and aged unpaid claim follow up.

Requirements

Ability to communicate in English, both orally and in writing
Strong interpersonal and communication skills
Ability to work within a team environment
Ability to effectively communicate with providers, leadership, clinical staff and insurance contacts
Ability to use problem solving and critical thinking skills
Multi-tasking, organizing and priority setting
Experience with Standard Office Equipment (Phone, Fax, Copy Machine, Scanner, Email/Voice Mail)
Experience Standard Office Technology in a Window based environment & Microsoft Office Suite
Knowledge and Experience in Credentialing Software, Preferred
Associate Degree
3+ Years’ relevant experience preferred

Nice To Haves

Bachelor’s Degree preferred
CPCS Certification (Certified Provider Credentialing Specialist) preferred

Responsibilities

Maintain credentialing policy and procedure compliance with state law and regulation, SMG policy and accreditation standards including maintenance of certification requirements.
Manage internal enrollment policies and checklists based on the published payer guidelines
Oversee that the procedures for credentialing and recredentialing are followed in a timely manner.
Provide appropriate forms and related correspondence to applicants in a timely manner.
Monitor proper completion of all forms in a timely manner.
Process and verify all information provided by applicants in reference to education, training, and experience.
Establish and maintain a complete and current credentialing file for each applicant and participating provider.
Audit all payer enrollment files to ensure current and accurate information
Work with payers to ensure the payer enrollment files and on-line directories are updated accurately and in a timely manner
Manage and perform quality audits of NPPES to ensure accuracy of provider NPI numbers and taxonomy codes
Work closely with clinical staff and communicates with providers to obtain and verify the documentation and signatures necessary to process Medicare/Medicaid Revalidations
Follows up with commercial and government payers to ensure enrollment and demographic information for all newly credentialed providers is uploaded into the payer systems and provider on-line directories
Maintain current and accurate payer rosters for all the contracted health plans
Researches and implements new processes and workflows as they pertain to enrollment and data management
Work with Revenue Cycle for appropriate set up for electronic claims submission and electronic remittance advice
Ensure that applications are properly completed following a standard format established by the health plans (applicable to SMG and the practitioner’s hospital privileges).
Maintain files and records of all actions taken concerning each applicant.
Responsible for ensuring providers obtain and maintain required privileges at outside facilities prior to start date and on an on-going basis.
Accurately maintain a physician database containing individual credentials information.
Ensures that credentialing program is updated daily with current individual provider data.
processing insurance claims for various types of insurance and maximizing SMGOR reimbursement.
Responsible for claim resolution through working claims edits and appealing denied claims in a timely manner.
Track status of outstanding claims, follow up on outstanding AR balances and monitoring of payer response.
Provide detailed information regarding problem payers to management; provide suggestions for solutions to management.
Become familiar with requirements in delegated and non-delegated credentialing agreements with health plans at initial and renewal periods.
Maintain timely documentation tracking needed to meet reimbursement requirements.
Ensure that current and accurate Provider Insurance ID# grid is available daily.
Serve as a liaison between providers, health plans and healthcare entities to ensure accurate and timely credentialing and maintenance of privileges.
Assist Clinical Operations in the following Handling confidential and sensitive provider information,
Working with various departments (e.g. Legal, Risk Management, Quality, Revenue Cycle) to ensure a complete, compliant and timely process and information sharing as necessary.
Exhibit excellent internal and external customer service.
Develop a “working rapport” with all providers.
Proficient in EMR/HER
Understanding of investigation and handling of claim denials
Proficient in management and resolution of items in work queues