Senior Credentialing Specialist, TPR

Conifer Health Solutions • Dallas, TX

7d

About The Position

The Senior Credentialing Specialist will work closely with the local market onboarding team on all new providers in the pipeline. This role involves requesting credentialing data and supporting documents from physicians, communicating potential delays to the market onboarding team, and preparing/updating CAQH applications. The specialist will also build and maintain relationships with health plans, strategically communicate newly affiliated providers, and establish credentialed status to facilitate billing. Key responsibilities include maintaining credentialing databases, executing standard operating procedures, identifying process improvements, and resolving issues related to billing and collections. Additionally, the role involves educating internal markets on payor contractual obligations and providing credentialing information to Market Operations.

Requirements

• Minimum of five years of experience in a managed care role, centralized credentialing office or related health care environment, such as credentialing or file maintenance.
• Knowledge of health plan and governmental payer credentialing, enrollment, and requirements.
• Knowledge of CAQH application.
• Knowledge of contract language interpretation and administration.
• Ability to work within a deadline-intense environment.
• Demonstrated problem-solving and customer service skills.
• Knowledge of Microsoft Word and other PC applications.
• Excellent verbal and written communication skills.

Nice To Haves

• Knowledge of NCQA standards, delegated credentialing, and Primary Source Verification.
• Completion of an applicable Vocational or Technical training program preferred.

Responsibilities

• Work closely with the local market onboarding team on all new providers in the pipeline.
• Request all credentialing data and supporting documents from the physician.
• Communicate to market onboarding team when delays with the physician are in jeopardy of interrupting the defined project timelines.
• Prepare and/or update the provider’s CAQH application for newly affiliated and existing healthcare providers.
• Build and maintain peer-to-peer relationships with all relevant market Health Plans.
• Strategically communicate newly affiliated providers to plan to initiate TIN change/demographic flip or initiate credentialing.
• Establish credentialed status to facilitate billing.
• Maintain credentialing databases and ensures up-to-date tracking of file process.
• Execute all standard operating procedures (SOPs) as well as communicating issues, trends, and concerns to Regional Supervisor.
• Identify any opportunity for process improvement and work with Regional Supervisor to challenge payors agendas.
• Ensure all workflow items are completed within the set turn-around-time, meeting quality expectations.
• Issue resolution relating to billing and collecting for services rendered.
• Educate internal markets on contractual obligations for each payor surrounding managing authorizations, billing requirements and operationalizing language to ensure that we are able to bill and collect for services rendered.
• Provide credentialing information to Market Operations to ensure that they have the information needed to effectively manage the practices from a credentialing perspective.
• Data Entry- 5%
• Initial credentialing or recredentialing per NCQA- 30%
• Health plan submission (delegated, non-delegated)- 30%
• UCC credentialing- 25%
• Other duties as assigned- 10%

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED