Credentialing and Enrollment Specialist

MyMichigan Health•Midland, MI

1d•Hybrid

About The Position

Opportunity for remote or hybrid with home office in Midland Develop and oversee Clinically Integrated Network (CIN) credentialing process, develop and administer policy and procedural processes to support CIN credentialing/payer onboarding activities. This role is critical in maintaining compliance, ensuring timely payments, and facilitating efficient provider-insurer relations.

Requirements

At least three years of experience in healthcare credentialing, insurance enrollments, revenue cycle or a related field.
Knowledge of healthcare regulations, including HIPPA, Medicare, Medicaid and state laws.
Problem solving abilities to navigate complex administrative and regulatory landscapes.
Bachelor's degree in Business Administration, Healthcare Administration, or related field required.
Equivalent experience may be considered.

Nice To Haves

Certification in healthcare credentialing is preferred

Responsibilities

Support the entire credentialing process for healthcare providers, including gathering and verifying licensure, education, training, and malpractice insurance information.
Maintain accurate and up-to-date provider credential files in compliance with health plans and governmental regulations.
Collaborate with providers to ensure all required documentation is submitted accurately and promptly for credentialing applications.
Maintain databases and electronic systems used for credentialing and payer management.
CIN Credentialing Committee oversight
Subject matter expert for credentialing & delegated credentialing activities
Validation of the physician credentialing data with CIN credentialing policies/procedures
Presentation of complete credential files to CIN Committee for review and evaluation.
Stay abreast of changes in credentialing standards and payer requirements, adjusting processes accordingly to maintain compliance.
Conduct periodic audits to ensure compliance with credentialing standards and insurance contracts.
Manages and follow up on open issues.
Provide ongoing support and guidance to healthcare providers regarding credentialing status and payer relations.
Conduct onboarding process for CIN physicians and practitioners
Develop routine and consistent payer roster submissions in compliance with payer elements.
Execute annual payer audit process.
Collaboration with MyMichigan Health CVO and Provider Enrollment
Database management systems support
Ensures data integrity, confidentiality, and security in accordance with HIPPA and other relevant regulations.
Verification and maintenance of provider database elements to include as examples: demographics, licenses etc.
Preparation of credentialing reporting metrics.
Prepares reports/rosters for end user applications.
Assists in network assessments and special database reporting requests from payers.
Identifies opportunities for Process Improvement and makes recommendations for operational effectiveness.