GENERAL DESCRIPTION OF POSITION: Responsible for the oversight and coordination of credentialing and re-credentialing of all providers and facilities to fulfill government credentialing regulations and are properly enrolled with insurance agencies. Understands specific application requirements for each payer including pre-requisites, forms required, supporting documentation and regulation. Knowledge of provider credentialing and its direct impact on the practice revenue cycle. Great customer service and telephone etiquette, computer knowledge, professional appearance, attention to detail, able to multitask and work in a fast-paced environment. Ability to work well under stress and maintain calm under pressure and work well with team members and willingness to cross-train. Functions as a member of a collaborative health care team to create and maintain a patient centered medical home
ESSENTIAL JOB FUNCTIONS: (With or without accommodations)
Communication: Communicates with providers, outside providers offices and insurance representatives by telephone in a pleasant, culturally and linguistic manner or by secure email. Assure all questions are answered or resolved in a positive and cordial manner regarding credentialing/enrollment of providers, facilities or insurances to meet deadlines. Communicates unresolved issues to the supervisor or designee as needed
Essential Functions and Responsibilities:
- Manage the completion and submission of provider enrollment applications
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Perform tracking and follow up to ensure providers, facilities are established timely and linked to appropriate entity.
- Retain records related to completed enrollment applications.
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Process applications for providers for re-credentialing with facilities and payers.
- Responsible for tracking credentialing expiration of facilities and providers with accuracy and timeliness.
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Works with other staff to streamline and improve processes related to credentialing and provider data
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Obtains appropriate paperwork, reviews applications, and prepares verification letters
- Ensure insurance directories are correct and up to date
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Update providers/facility CAQH database file timely according to the schedule published by CMS
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Complete revalidation requests issued by government or insurance payers
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Complete credentialing applications to add providers to insurance payers.
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Works closely with supervisor and billing staff to identify and resolve any denials or authorization issues related to credentialing.
- Maintain accurate provider/facilities profiles on CAQH, PECOS and CMS or any other database.
- Works on daily correspondence from insurances
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Responsible for insurance, provider and EDI set-ups in Centricity
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Responsible for new and/or amendments for insurance contracts
- Travels to different clinics to obtain required information needed for credentialing.
- Other duties assigned
Team Communication: works closely with appropriate staff to resolve issues with the credentialing process to ensure proper deadlines are met. Educates staff on credentialing process and standards as needed.
Management of Documentation: Maintains appropriate documentation and reporting regarding the credentialing process (application, DEA, liability insurance, etc) for each provider and facility.
Demonstrates Safe Professional Conduct: Maintains a friendly environment for self and others. Refrains from texting and speaking on the cell phone. Refrains from informal communication with patients and others. Fully participates in performance improvement and follows all Clinic policies and procedures. Attends work on a regular and predictable schedule in accordance with clinic leave policy and performs other duties assigned. Submits required documentation in a timely manner.
POSITION DIRECTLY SUPERVISED: None
KNOWLEDGE, SKILLS, AND ABILITIES: (use of equipment, job related knowledge, language, etc.)
Skilled in billing and coding
Ability to fully comply with the enhanced infection control requirements of the clinic.
SPECIAL INSTRUCTIONS:
This position requires travel. Employee must provide transportation. If employee operates a personal motor vehicle in the performance of their official duties, the employee must possess a current valid Texas driver’s license for the appropriate type of vehicle and Texas Liability insurance.
Due to the nature of SC Services, it may be necessary for employees to work extended hours or other variations of the usual shift to ensure adequate care to patients, maintain service to the community and to meet the department needs.
