Credentialing Specialist

Enhanced Revenue Solutions, Inc by Infinx Healthcare

Summary Description:

Under general direction, this position will provide full service credentialing for individual physicians, group practices and physician facilities with a focus on CMS/Medicare enrollments and reappointments. Persistent follow-up and follow through is a requirement. Utilize a variety of proprietary and external tools in order to research and resolve provider enrollment issues. This may require contact with the payer networks, operation personnel and/or insurance companies via phone, email or website.

Daily Responsibilities:

• Understand specific application requirements for CMS (Medicare) including prerequisites, forms required (paper and electronic submissions), form completion requirements, supporting documentation and CMS/Medicare guidelines
• Understand the CMS/Medicare systems such as Identity and Access Management System (I&A) and online enrollment management system (PECOS)
• Understand appointment of representative process to act as physician/group representative in connection with CMS/Medicare I&A portal managing, Change of Ownership (CHOW), initial enrollment, revalidation and facility adding for individual physicians, group practice and physician facility (855I, 855R, 855B)
• Document Tracking: Tracking with advanced notification of expiring physician and facility documents to act as the liaison between the insurance carrier(s) with all matters relating to the credentialing / recredentialing process.
• Credentialing Documentation: Maintaining all pertinent Credentialing documentation (e.g. DEA, CDS, Medical Licenses, Board Certificates, Malpractice Insurance Face Sheets, CMEs, etc.)
• Distribution of Renewed Documentation: Ensuring that all renewed documents (including DEA, CDS, Malpractice Insurance Face Sheets, Medical Licenses, updated CMEs, etc.) are updated on CMS/Medicare portal (PECOS)
• Create detailed insurance matrix for each practitioner which lists the individual physician, each insurance carrier and the physician’s status with the plan, (updated each time there is a change in status)
• NPI (National Provider Identifier) Management: NPI implementation and Maintenance in the NPPES system
• Performs follow-up with Physicians, Insurance carriers as needed in order to research and resolve provider enrollment issues
• Performs follow-up with insurance payers via phone, email or website to resolve payer credentialing issues
• Manage the completion and submission of provider enrollment applications
• Work closely with site management and resources to expedite completion of forms and requirements including obtaining signatures, locating required documentation, etc.
• Establish close working relationships with privileging coordinators, contracting department, medical management, and payer contacts
• Maintains strict confidentiality with regard to protected health information understands
• Perform administrative and technical duties to support the credentialing functions of initial appointment, reappointment, the granting of clinical privileges, and maintenance of expirables in accordance with hospital medical staff bylaws and credentialing policies and procedures
• Work to ensure that timely and accurate initial and reappointment applications are presented to the department chairs/credentials committee/medical executive committee for review
• Populate, maintain, and update credentialing software including accountability for the integrity of credentialing information they enter into the credentialing data tracking system
• Identify, investigate, report, track, and follow-up on all potentially adverse information received from credentialing sources according to established guidelines and hospital credentialing policies and procedures
• Communicate appointment, reappointment, and clinical privilege decisions and changes to any external and internal parties as directed and in accordance with credentialing policies and procedures

Skills and Education:

• High School Diploma or GED required
• Bachelor’s degree preferred in healthcare, accounting, or business administration
• 3 + years of credentialing experience preferred
• Knowledge of CMS/Medicare and PECOS is preferred
• Proven ability to work in a fast-paced environment, and deliver results for multiple stakeholders
• Demonstrated knowledge of credentialing and privileging principles, concepts, standards and regulations
• Highly detail oriented, creative and proven problem solver
• Strong attention to detail and ability to analyze
• Strong project management, problem resolution and communication skills
• Excellent organizational skills and ability to prioritize workload in ever changing environment
• Strong MS Office Suite skills (Word, Excel, PowerPoint and SharePoint) and proven ability to learn/use company specialized software and hardware
• Strong work ethic and high degree of professionalism
• Motivation, energy and ability to work both independently and collaboratively

Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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