|Contracts and Credentialing Specialists|
- Job ID
- Regular Full-Time
- Mental and Behavior Health
Responsible for initiating, coordinating, monitoring, and maintaining enterprise-wide contracts and credentialing processes with health plans/funders. Facilitates all aspects of Intermountain Centers practitioner credentialing, in accordance with state, federal and health plan/funder requirements, , policies and/or procedures. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications.
- Ensures licensed independent practitioners and medical providers meet credentialing requirements as set forth by each contracting health plan, including AHCCCS health plans and Medicare.
- Collaborates with clinical staff to draft, compile and submit all necessary credentialing documents necessary to implement the credentialing process; obtains provider signatures, certificates of insurance, DEA#s, etc.,
- Performs initial review of credentialing documents to ensure practitioner is in good-standing with regulatory agencies.
- Identifies issues/discrepancies that require additional review and follow-up.
- Completes requests for Medicare, AHCCCS IDs, CAQH, NPI and other steps needed for the credentialing process.
- Performs updates to credentialing files and/or profiles as needed to ensure provider information is accurate.
- Tracks and monitors provider credentialing/re-credentialing applications from submission to completion.
- Loads provider information into credentialing database/tracking document or provider specific folders.
- Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
- Assists with credentialing audits; conducts internal file audits.
- Performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
- Monitors the initial, reappointment and expirables process for all Behavioral Health Medical Professionals and Independently Licensed Professional staff, , 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.
- Responsible for following all policies, procedures, and controls established by the organization, the HIPAA Privacy Officer, and/or the HIPAA Security Officer regarding access to, protection of, and the use of the PHI.
- Performs other related duties as assigned.
- Reviews contracts and contract amendments for fee schedules and other terms and provide feedback to executive leadership.
- Maintains contract files with health plans and other state or federal funders, managed care organizations, and state Medicaid systems.
- Handles all communications and escalations while working the in-networking process.
- Tracks re-credentialing deadlines and file re-credentialing paperwork, as well as any changes in credentialing (such as change of address, etc.).
- Manages open items and deadlines to ensure timely processing of applications and execution of contracts.
- Monitors and tracks submissions and status changes with payers and update internal records.
- Maintains and updates existing records and create new records and reports.
- Supports executive leadership and directors with special projects and perform other duties as assigned.
- Maintain an approachable and appropriate attitude when communicating with internal and external clients and respond timely to requests, emails, voicemails, etc.
- Ability to be very discrete with confidential information.
- Possesses ability to work independently as well as part of a team with flexibility and willingness to learn and take initiative on variety of tasks and projects in a dynamic environment.
- Ability to work independently, with a high degree of self-motivation, goal achievement orientation and strong practical problem solving acumen.
- A high level of accuracy, attention to detail, and process orientation with strong organizational and multi-tasking skills.
- Exceptional written and verbal communication, interpersonal and customer service skills.
- Excellent computer skills, including but not limited to Word, Excel, Outlook and other Microsoft Office products. Knowledge of related accreditation and certification requirements.
- Skill and experience in reviewing contracts.
- Knowledge of medical credentialing and privileging procedures and standards.
- Ability to analyze, interpret and draw inferences from research findings, and prepare reports.
- Working knowledge of clinical operations and procedures.
- Informational research skills.
- Ability to use independent judgment to manage and impart confidential information.
- Database management skills including querying, reporting, and document generation.
- High school diploma or GED;
- At least 5 years of experience in a new healthcare payer enrollment, contracting and credentialing role, preferably with a behavioral health agency.
- Prior professional contacts and relationships with payers preferred, but not required.
- Certification/Licensure NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) preferred.
- Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.
|Job Reference #: ||1678|
|Job Status: |
|Date Posted: ||11/26/2018|
|Pay Rate: |
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