Sr. Physician Credentialing Enrollment Specialist

Northside Hospital Inc.•Sandy Springs, GA

21h

About The Position

Northside Hospital is award-winning, state-of-the-art, and continually growing. Constantly expanding the quality and reach of our care to our patients and communities creates even more opportunity for the best healthcare professionals in Atlanta and beyond. Discover all the possibilities of a career at Northside today. The Senior Physician Credentialing Specialist provides the infrastructure management in support of the credentialing and re-credentialing processes for the Managed Care department through analysis, research, documentation, communication and system maintenance. Demonstrates competency in all aspects of the enrollment and credentialing processes of providers and is instrumental in their successful application to participate with over 25 affiliated health care plans/ products, as well as Medicare and Medicaid. Mentors and trains other staff members.

Requirements

High School diploma or GED preferred or 3-5 years of work experience.
Advanced skills with Microsoft applications which may include Cactus, Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
Knowledge of Medicare, Medicaid and health plan credentialing, recredentialing and enrollment process; licensure requirements and regulations of various agencies such as the board of Registration in Medicine, American Board of Medical Specialties and Individual Specialty Boards preferred normally acquired through related work experience.

Responsibilities

Creates Standard Operating Process for provider application process for credentialing with Managed Care.
Responsible for creating and maintaining accurate health plan application packets for the many different disciplines that fall under the aegis of NSH, keeping abreast of the numerous changes in application and licensure documentation. Provides oversight for the review of the returned applications for accuracy and completeness prior to upload into Cactus and then submission to the health plans.
Develops and maintains excellent working relationships with health plan contacts regarding provider enrollment and credentialing. Investigates and resolves enrollment problems with health plans that are impeding proper billing and reimbursement.
Mentors and trains other staff members relative to the credentialing process from applicant status to successful participation status
Responsible for optimal utilization of the Cactus credentialing database, to ensure efficiency for the Managed Care team
Independently designs and interprets reports from Cactus that will be utilized to ensure plan submission and follow-up to ensure plan participation
Collaborate with Managed Care team to outline and successfully implement delegated credentialing
Once delegation status is achieved will monitors the initial, reappointment and expirables process for all delegated providers, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
Will work collaboratively with Manager and Medical Staff Office personnel in preparation for Managed Care delegated credentialing audits by the plans.
Leads or coordinates special projects, as assigned.
Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Immediately reports any mechanical or electrical equipment malfunctions, unsafe conditions, or employee/visitor/patient injury or accident to Manager.