Credentialing Specialist

Rogers Behavioral Health•Oconomowoc, WI

About The Position

The Credentialing Specialist is primarily responsible for activities impacting facility and practitioner external provider enrollment and credentialing; this includes all network application and maintenance processes that impact facilities and applicable practitioners employed or contracted by Rogers Memorial Hospital, Inc. In all activities, the Credentialing Specialist must remain aware of and comply with legal, regulatory, and financial policies and procedures. The Credentialing Specialist is in regular contact with payer strategies, medical office staff, financial services, physicians/ practitioners, and contracted payer staff. The Credentialing Specialist is responsible for maintaining up-to-date file information on payer enrolled practitioners in multiple systems, answering inquiries regarding a provider’s network status, and collaborating with colleagues to ensure the accuracy of facility contracted networks and affiliations. The candidate must live in one the following states: WI, CA, GA, FL, MN, IL, CO, PA, TN, or WA

Requirements

Associate’s degree or 2 years' experience
Administrative skills, including computer/word processing
Computer proficiency, adaptability and working knowledge of Microsoft Office, Adobe and Excel
Exceptional critical thinking skills and sound judgement
Exceptional written, verbal, and auditory skillset
Ability to perform all essential job functions either on site or remotely

Nice To Haves

Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards
General understanding of health insurance plans, provider enrollment processes, payer contracting and remittance processes, and HIPAA and healthcare compliance
Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment
Symplr Experience
Experience with CAQH (Council for Affordable Quality Healthcare) database and application process
Prior professional history in a medical or mental health setting
NAMSS/CPCS Certification

Responsibilities

Provider Enrollment Application Processing
Maintain understanding of RBH Privacy Practices, HIPAA, Medical Staff standards, state and federal= requirements, and other applicable corporate and departmental policies.
Responsible for facility and practitioner enrollment activities, maintaining up to date file information in multiple systems, answering inquiries related to network status, collaborating with colleagues to ensure accuracy of facility contracted networks and affiliations
Recommend policy and procedural updates as applicable
Maintain standard outreach to on-boarding medical staff providers detailing initial and ongoing provider= enrollment requirements
Maintain knowledge of all data and document locations required as part of the enrollment process
Maintain knowledge of standard work detailing contracted payer provider credentialing processes for all exclusive contracts.
Communicate accurate RBH location and demographic information
Populate and maintain both facility and provider level information in the CAQH system
Enroll and maintain facilities and practitioners in all appropriate contracted health plans
Enroll practitioners with government payers using electronic application methods such as PECOS and portals
Populate credentialing software with timely and accurate provider status and affiliation information
Monitor and disseminate affiliation, application and revalidation status upon request and as applicable
Maintain privacy and confidentiality at all times.
Establish and maintain positive and cooperative working relationship with Payer Strategies team
Remain aware of contractual adjustments that may impact provider affiliations and/or payment
Establish and maintain positive and cooperative working relationship with all Patient Financial Services team= professionals
Populate and maintain Symplr Provider information referenced by PFS staff to investigate and appeal= professional claim denials
Establish and provide ongoing assist with PFS staff Symplr Provider logins
Regular written and verbal communications with payer group representatives at multiple levels
Respond to all applicable payer outreach for information and/or clarification
Complete projects as assigned by Credentialing Manager
Regular assistance with and dissemination of payer communications impacting other departments
Participate in process improvement events and activities
Serve as a back-up to other Payer Strategies positions on an as-needed basis.
Assist in promoting a team atmosphere by treating individuals with respect and honesty and by using direct= communication and active listening skills.