Credentialing Payer Specialist

• Essential Job Accountabilities:

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    Job Summary:
    • The Credentialing Payer Specialist coordinates, manages, and facilitates all required provider enrollment activities for the NCH Physician Group Revenue Cycle Department for participation with all government and third-party payers. The Credentialing Payer Specialist acts as liaison with the NCH Health System Physicians Services, Contract Management and others facilitating communication between the departments, providers, and payers when necessary, ensuring all required documentation is received timely. Promotes and enhances good communication and positive working relationships between the Physician Group and the Medical Staff. Above all, this position serves to exceed the expectations of patients and all other customers we serve.
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    Essential Duties and Responsibilities:
    • • Coordinates and provides administrative support for the payer credentialing process (initial provider enrollment and re-enrollment).
      • Initiates credentialing and provider enrollment activities in a timely, comprehensive, and well-organized manner, per established policies and procedures.
      • Upon receipt of a completed initial provider enrollment application, coordinates information collection, verification, and documentation, enters data in the physician profiling data base per established policies and procedures.
      • Facilitates on-boarding efforts through collaboration with Recruitment, Medical Staff, Human Resources, and additional departments as needed.
      • Coordinates and facilitates gathering required documentation in order to successfully process and enroll providers with third party payers, obtain staff privileges, and obtain malpractice insurance as needed. Work closely with the appropriate leadership, departments, and staff to complete the processes.
      • Closely monitors information collection, makes cognitive analysis of all information received, appropriately evaluating the quality of the documentation received, pursuing additional information, if necessary, for effective, comprehensive, and successful provider enrollment.
      • Immediately reports to Senior Director of Revenue Cycle, Assistant Director of Revenue Cycle, and the Medical Staff Services office, all information which is adverse to the provider enrollment application(s) (i.e. credentialing issues, adverse letters, gaps on application, peer review recommendations, disciplinary actions, etc.).
      • Performs timely follow up for all outstanding provider enrollment applications and contracts.
      • Prepares a weekly status report to send to management and designated staff providing updated status of all pending applications and tasks.
      • Plans, develops, and provides for supporting provider enrollment documentation for NCH Physician Group departments/committee meetings.
      • Attends meetings, prepares, and maintains accurate minutes, and processes follow up needs to facilitate effective provider enrollment, documentation, communication and otherwise maintains all necessary filing for assigned meetings ensuring minutes are completed within two weeks of meeting dates.
      • Monitors department/committee activities to identify and address provider enrollment needs.
      • Prepares all necessary reports to include all required information for submission to other departments related to provider enrollment.
      • Understand Provider Enrollment requirements to ensure regulatory compliance, including but not limited to CAQH, NPPES, PECOS, JCAHO and NCQA standards, through ongoing review.
      • Maintains documentation of all provider enrollment records with required supporting information for periodic provider re-enrollment, re-certification, and regulatory surveys. Ensure that all provider enrollment files are maintained in an appropriate manner on an ongoing basis.
      • Maintains accurate and current demographic data for all providers of the NCH Physician Group.
      • Enters current demographic information into the designated healthcare system database as well as the department-specific physician profiling data base, including additions/deletions to the licensed provider staff/AHP staff and all other changes needed to keep the system accurate on an ongoing basis.
      • Consistently uses all approved abbreviations, specialty listings and other unique information to ensure the integrity of the data base.
      • Maintains skill level to run all required reports from current demographic data base on an ongoing basis.
      • Facilitates delegated credentialing functions through collaboration with the Medical Staff Office and third-party payers.
      • Obtains and coordinates submission of requested files to third party payers for initial consideration and ongoing maintenance of credentialing delegation to the NCH Physician Group.
      • Coordinates all payer audits required to comply with delegated credentialing contracts between the NCH Physician Group and third-party payers.
      • Attends all onsite payer audits required to maintain direct delegation contracts with third party payers and reports all outcomes to NCH Physician Group CBO Leadership.
      • Liaison between NCH Physician Group Central Business Office, governmental and third-party payer Provider Enrollment Teams.
      • Establishes professional relationships with governmental and third-party payers, to include local area IPA’s, PHO’s, and MSO’s as needed.
      • Facilitates resolution of payer related credentialing issues to include those based on non-payment and inaccurate provider payments.
      • Notifies Payers of demographic changes for Physician Offices and treating providers.
      • Project manages complex payer issues to achieve satisfactory resolution of nonpayment or inaccurate payment issues.
      • Coordinates payer in-service meetings as needed or as requested by leadership to further payer relations and facilitate resolution of complex payer issues.
      • Develops and maintains a system for ongoing validation of 100% accuracy of data stored in CAQH, NPPES, PECOS and EDI enrollment systems.
      • Audits all databases, at least annually, to ensure 100% accuracy of provider data stored in each database.
      • Performs root cause analysis for any errors found and takes required action steps to resolve all inaccuracies.
      • Notifies NCH Physician Group CBO leadership of errors identified in a timely manner. Reports all progress to designated leadership through completion resolution.
      • Monitors success of all corrective action related to resolution of database inaccuracies to ensure 100% accuracy of provider data stored in various repositories going forward.
      • Assists with internal training of NCH Physician Group managers, providers, staff, of any changes related to provider enrollment.
      • Facilitates scheduling of all meetings and educational opportunities with provider representatives related, but not limited to provider enrollment processes.
      • Performs all work in a professional manner with the utmost discretion and strict confidentiality.
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    Education, Experience, Qualifications:
    • • Minimum of High School or GED required.
      • Minimum of 1 year of experience in a medical office required, 2 years of experience in credentialing/provider enrollment preferred.

PI218968022