JOB TYPE: / Credentialing Specialist
HOME COMPANY: / Villages Health System, LLC
HOME BUSINESS UNIT: / The Villages Health
REPORTS TO: / Physician Recruiter
FLSA STATUS: / Exempt
PRE-REQUISITE: / none
UPDATED/REVIEWED: / 12/12/17
FILE CODE:
SCOPE OF RESPONSIBILITIES

Under general supervision, the Credentialing specialist's primary responsibility is to perform on a daily basis the credentialing/re-credentialing of providers for the Villages Health, LLC. This process includes review of credentialing packet upon return by Provider, primary source verification, preparation/maintenance of provider files, and data entry. The Credentialing Specialist will assist with file and report preparation to be reviewed by the Chief Medical Officer, Chief Financial Officer and Chief Executive Officer. The Credentialing Specialist works closely with the Revenue Cycle Managerand Provider Recruiter in maintaining network integrity.

.ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different functions be performed when circumstances change or exigencies require (this includes but is not limited to emergencies, changes in personnel, workload, rush jobs, or technological developments).
  1. Organizes and overs the credentialing and payor enrollment process with all participating health plans.
  2. Coordinates the gathering and verification of necessary data, working directly with providers or appropriate representatives.
  3. Complete applications accurately and thoroughly, meeting standards set forth by CMS.
  4. Obtain application signatures from the authorized signatory and provide all required supporting documentation.
  5. Liaison with malpractice agency to insure providers.
  6. Inputs provider information and completes the electronic credentialing process through the ECHO electronic system; maintains provider electronic data files when changes are identified
  7. Submit applications and follow process to ensure progress.
  8. Maintain the accuracy of provider CAQH profiles and coordinate re-attestation every 120 days.
  9. Respond to deficiency notification in a timely manner. Attain, verify, and disseminate state required billing numbers and approval letters as needed.
  10. Serve as liaison between health plans and TVH in resolution of issues related to credentialing and plan participation.
  11. Create, maintain, and disseminate plan participation status and billing information to billing, managers, and executives to maximize collections in the revenue cycle management process.
  12. Stay abreast of insurance terms and regulatory changes by researching legislation and state requirements. Research accrediting organization requirements. Service as an educational resourceon the subject of credentialing and payor-specific participation requirements.
  13. Establish policies and procedures consistent with NCQA standards. Develop and maintain a Managed Care Credentialing and Provider Enrollment Manual, which includes detailed instructions on payor-specific application requirements for participation with Medicare, Medicaid, and commercial health plans. Continuously analyze the effectiveness of the current credentialing process and create departmental strategies for reducing delays in participation.
  14. Work on special projects as assigned.

TIAL DUTIEES include the following. Other duties may be assigned.

EDUCATION/EXPERIENCE REQUIREMENTS
  • Associates in Medical Staff Services Preferred.
  • Certified Provider Credentialing Specialist (CPCS certification) Preferred
  • 3-5 years of experience with credentialing for hospital, primary care and multi-specialty groups

KNOWLEDGE/SKILLS/ABILITIES
  • Proficient in Microsoft Office (Excel)
  • Complete understanding of major health plans including Medicare, UHC and BCBS
  • Ability to communicate clearly with all levels of management, and providers.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

  • Regularly required to sit and repetitively use hands to write and operate computer, calculator, etc.
  • Occasionally required to stand, climb or balance, stoop, kneel, crouch or crawl and reach with hands and arms
  • Regularly lift and/or move up to 10 pounds and may lift a 25-50 lb box occasionally
  • Specific vision abilities required by this job include close vision and ability to adjust focus

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

  • Occasionally exposed to moving mechanical parts and risk of electrical shock when working with or near office equipment
  • The noise level in the work environment is usually moderate

ACCESS TO PROTECTED HEALTH INFORMATION (PHI)

WORK ENVIRONMENT

This position requires FULL access to Protected Health Information (PHI), and will adhere to HIPAA regulations regarding PHI.

mployee and supervisor have reviewed the above job description and determined that it accurately reflects the position. Employee acknowledges and agrees that he/she is qualified to perform the essential functions of the position [with] or [without] accommodation.

Employee Name:

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Employee SignatureDate

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