[Hiring] Credentialing & Enrollment Representative @Medusind

Role Description

Under the direction of the Provider & Enrollment and Contracts Manager, the Credentialing & Enrollment Representative evaluates, analyzes, and coordinates all aspects of the credentialing and recredentialing processes of clinical providers (Medical, Dental, Optometry, and Behavioral Health) and clinics with participating health insurance plans.

Responsibilities

• Credentialing & Provider Enrollment:
  • Enroll with health plans using accurate and detail orientation to complete health plan enrollment applications and submit enrollment to payors in a timely manner.
  • Deep understanding of health plans including CAQH, Medicare, Medicaid, Managed Care, and Commercial Plans.
  • Determine re-credentialing dates and complete re-credentialing of all providers and clinics (groups) with appropriate health plans.
  • Maintain all enrollment data and follow-ups with health plans in centralized spreadsheets for each client.
  • Possess knowledge and ensure CAQH are created and updated on a quarterly basis.
  • Enter, update, and maintain data from provider applications into the credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, in accordance with internal policies and procedures.
  • Ensure all provider demographic information as well as NPPES is kept up to date at all times.
  • Participate in agenda prep meetings as well as client calls at all times.
  • Electronically prepare, track, and follow-up on appropriate verifications for efficient, high-volume processing of individual provider applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines.
• Reporting & Analytics:
  • Monitor files to ensure completeness and accuracy; review all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies.
  • Identify, analyze, and resolve extraordinary information or discrepancies that could adversely impact the ability to credential and enroll practitioners.
  • Be prepared to provide feedback and give updates pertaining to credentialing and health plan enrollment for providers and clinics.
• Collaboration & Communication:
  • Communicate clearly with providers, their liaisons, medical staff leadership, and Administration, as needed to provide timely responses.
  • Communicate regularly with colleagues, management, health plans, and providers at all times.
  • Be available for all internal and client meetings in a timely manner.
  • Take initiative and respond proactively to all identified issues.
  • Problem-solve and come up with solutions to credentialing problems and report to management when necessary.
  • Think outside the box and identify issues and problems before they happen.
• Continuous Improvement:
  • Maintain current and accurate records of provider and credentialing provider data, including initial and re-credentialing.

Qualifications

• Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field (preferred).
• A minimum of 2 years of full-time experience in all facets of credentialing, including interactions with healthcare providers.
• Experienced with Medicare, Medi-Cal, Managed Care, and Commercial insurances.
• Strong knowledge of Federally qualified health centers (FQHCs) and Community Health Centers (CHCs).
• Strong ability to collaborate with cross-functional teams.
• High level of accuracy, with the ability to set and maintain priorities in a fast-paced environment.
• Strong knowledge in the use of Microsoft Excel, Word, and Outlook.
• Should be able to adapt to changes in regulations, technologies, and industry trends and adjust accordingly.