Provider Enrollment and Credentialing Representative

Sonic Healthcare USA•Palm Beach Gardens, FL

2d•Remote

About The Position

The Provider Enrollment & Credentialing Representative will be accountable for the initiation of new credential files, ensuring the completeness of a new application as the first step in the credential's verification process, and participating in verification of credentials through correspondence, phone contact, internet sites and any other third-party vendor. This is a remote opportunity. In this role you will be responsible for the initial credentialing and re-credentialing of physicians, obtaining and ensuring Medical Licenses are current, overseeing the maintenance of all certifications required to license and credential physicians (excluding laboratory CLIA licenses), coordinating and monitoring the review and analysis of practitioner applications and accompanying documents, conducting thorough background investigations and primary source verification, identifying and validating discrepancies, preparing credentials files for committee presentation, managing CAQH files, and processing Provider Enrollment requests in compliance with commercial and government payer criteria.

Requirements

Bachelor’s Degree or the equivalent years of experience.
Four years related experience; or equivalent combination of education and experience.
Ability to solve complex problems to support the planning, organizing, and coordinating of provider payer credentialing.
Knowledge of medical terminology, insurance billing, credentialing and licensing processes as demonstrated by work experience and education.
Must be able to effectively respond to questions from managers, employees, and outside entities.

Responsibilities

Initial credentialing and re-credentialing of physicians.
Obtains Medical Licenses as required, as well as ensures that all Aurora Medical staff meet and maintain active licensure.
Oversee the maintenance of all certifications required to successfully license and credential all physicians with the exception of the laboratory’s CLIA licenses.
Coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
Conducts thorough background investigation, research and primary source verification of all components of the application file.
Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
Prepares credentials file for completion and presentation to Entity Credentialing Committees, ensuring file completion within time periods specified.
Responsible for CAQH files for providers to ensure completion and maintain revisions/updates.
Processes requests for Provider Enrollment ensuring compliance with criteria outlined in descriptions for both commercial and Government payers.