Credentialing Healthcare Plan Specialist
Essential Duties and Responsibilities:
The HP Credentialing Specialist, under general supervision, work with physicians and allied health providers to facilitate the health plan credentialing / enrollment process to ensure that complete and accurate information is forwarded to health plans in a timely manner. As required by Credentialing Department policy, initiate follow-up with providers and health plans to ensure the process is continuing without unnecessary delays. Follow process to completion resulting in provider becoming contracted and receiving a specific provider identification number from each health plan in order for the billing process to commence.
- Process health plan enrollment / credentialing applications for physicians and allied health providers.
- Review and analyze provider’s returned paperwork to ensure completeness of information.
- Identify and flag adverse information received from materials completed by the provider for the purpose of conducting special investigation; reporting this information to the Credentialing Specialist for follow-up.
- Maintain tickler system outside of the credentialing database for follow-up of outstanding paperwork and unanswered correspondence according to schedules designed to maintain department standards for application processing time.
- Run weekly reports from the credentialing database to determine required follow-up with providers and health plans.
- Enter contact and action notes into credentialing database to maintain accurate record of progress with health plans.
- Maintain credentialing database and billing database updating provider health plan identification numbers and other required database fields.
- Organize and maintain provider health plan files and information following confidentiality guidelines.
- Share updated information (i.e., address changes, updated licensing or certification documentation) received from the provider during the enrollment / credentialing process with the Credentialing Specialist for input into the credentialing database.
- Employ public relations skills in a wide variety of contacts with internal and external sources for purposes of soliciting information essential to health plan enrollment / credentialing.
- Establish and maintain a professional working relationship with providers, their outside office staff, internal staff, and health plan staff.
- Proficient in the use of Visual Cactus (credentialing database) to enhance the health plan credentialing process and become proficient with its reporting functions.
- Proficient in the use of Microsoft Word and Excel for Visual Cactus; NPI (National Practitioner Identification on-line access); Certifacts (American Board of Medical Specialties on-line access); State licensing agencies on-line access and Internet Explorer for other internet access.
- Perform varied clerical / secretarial support functions
- Perform related duties as assigned by supervisor.
- Maintain compliance with all company policies and procedures.
- One year of credentialing or medical administrative experience in a hospital, managed care, or physician office practice setting is preferred.
- High school diploma or equivalent
- Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.
- Understanding of the basic process for enrolling / credentialing providers with health plans.
- Understanding of each health plan’s requirements for completion of all necessary paperwork needed for credentialing / enrollment process.
- Understanding of the need of the credentialing process in the health care environment and the impact on quality patient care.
- Basic knowledge of claims billing and/or contracting
- Familiarity with the National Association for Quality Assurance Standards and Guidelines for MCO accreditation.
- Problem solving and decision making
- Understanding/compliance of HIPAA laws and regulations
- Computer proficiency (MS Office – Word, Excel and Outlook)
- Highly organized with excellent attention to detail and a demonstrated high regard for clerical accuracy
- Excellent verbal and handwriting skills
- Ability to read, extract and interpret information comparing such to established departmental policies
- Excellent customer services and public relations skills required
- Must be flexible and willing to work extra hours during peak workloads and deadlines
- Ability to work as a team player with willingness to assist other team members as needed.
- Must be able to work under pressure and meet deadlines
- Self-motivated with the ability to work independently and to carry out assignments to completion within parameters of instructions given, established timeframes, prescribed routines, and standard accepted practices.
- Ability to operate standard office machines and equipment, including telephones, computers, copy machines, fax machines, calculators, scanners and shredders.
- Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards
- Ability to type __35__wpm
- Must be able to lift and carry up to 20 lbs
- Must be able to talk, listen and speak clearly on telephone
- Requires sitting and standing associated with a normal office environment.
- Manual dexterity needed for using a computer keyboard.
- Specific vision abilities include close vision, distance vision, depth perception and the ability to adjust focus.
Environmental Working Conditions:
- Normal office environment.
- The noise level of the work environment is usually low to moderate.
- Occasional overtime maybe required and/or hours may be shortened as business needs dictate.
*The job holder must demonstrate current competencies applicable to the position.
Job Status: Full Time