Provider Enrollment Credentialing Coordinator 1

Mercyhealth•Rockford, IL

3d•Onsite

About The Position

This role is responsible for understanding and maintaining in-depth knowledge of credentialing requirements for physicians with Wisconsin and Illinois Medicare, Medicaid, Blue Cross, and other third payers. The Coordinator implements and obtains NPI numbers, works with various departments to gather necessary information for new physicians to ensure timely completion of the credentialing process for claims payment, and investigates or follows up on claims work queues. The position also involves understanding facility enrollment, utilizing systems like CACTUS to manage credentialing information, ensuring confidentiality and accuracy, and initiating re-credentialing processes before expiration. Additionally, the role involves obtaining and maintaining information for credentialing Illinois physicians with each Mercy laboratory and the Illinois Department of Public Aid, processing this information in a timely manner, and monitoring expiration dates. The Coordinator is also responsible for obtaining provider numbers for Durable Medical Equipment (DME), monitoring expiration dates, and initiating re-certification. Maintaining current data in Cactus, ensuring confidentiality of personal information, communicating payer numbers to the Patient Accounts Application Analyst for the McKesson Plus system, and providing reports to various committees and departments are key responsibilities. The role also involves facilitating communication within the Mercy Health System regarding the credentialing process as an active participant on the Credentialing Committee, and developing, maintaining, and implementing policies and procedures to support credentialing, including educating partners on these policies.

Requirements

Associate's degree and 1 year of healthcare credentialing/enrollment experience preferred (healthcare facility, managed care setting, CVO, medical staff office, or enrollment), or a minimum of 5 years of experience in credentialing (preferred), or a minimum of 5 years of experience in a healthcare business support area required.
Three years' experience working with Wisconsin and Illinois Medicare and Medicaid credentialing regulations, plus managed care payers preferred.
Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Computer Skills: Knowledge of Patient Accounting software; Spreadsheet software and Word Processing software.
Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Nice To Haves

CACTUS experience a plus.

Responsibilities

Understands and maintains an in-depth knowledge regarding the requirements for credentialing physicians with Wisconsin and Illinois Medicare, Medicaid, Blue Cross and other third payers as necessary.
Responsible for implementing and obtaining NPI numbers per provider.
Works closely with the Medical Staff Office, Clinic Directors, Clinic Finance, Information Systems and physician recruiters to obtain necessary information on new physicians to complete the credentialing process, in a timely manner, necessary to get claims paid.
Understands the idiosyncrasies of the government forms, which forms are used and what information is necessary for credentialing physicians, physical therapists, CRNAs (Nurse Anesthetists), Physician Assistants, and residents.
Responsible for investigation or follow-up of claims work que.
Understands facility enrollment as appropriate.
Utilizes a system, such as CACTUS, to house and maintain all credentialing information, to include, but not be limited to: when applications are submitted, when payer numbers were received, and what numbers have been assigned to each individual, by location and payer.
Ensures confidentiality and accuracy of all credentialing information.
Utilizes the information in Cactus to ensure the re-credentialing process begins prior to any expiration of current statuses/numbers.
Obtains and maintains information necessary for credentialing Illinois physicians with each Mercy laboratory in Illinois with the Illinois Department of Public Aid.
Processes information on a timely basis and monitors expiration dates.
As appropriate, is knowledgeable and completes forms/documents as necessary for obtaining provider numbers for Durable Medical Equipment (DME) by location.
Monitors expiration dates and initiates the re-certification process in a timely manner.
Responsible for ensuring that all the data maintained in Cactus is current and that all personal information is kept confidential.
Responsible for communicating payer numbers received to a Patient Accounts Application Analyst to ensure the McKesson Plus system is current with the information necessary for timely billing of claims.
Provides reports as necessary for the Credentialing Committee, Patient Accounts, clinics, etc.
Facilitates communication within Mercy Health System on the credentialing process by being an active participant on the Credentialing Committee.
Develops, maintains, and implements policies and procedures necessary to support the credentialing process.
Responsible for educating partners in the application of the credentialing policies and procedures.