Summary

Responsible for credentialing and re-credentialing of practitioners, provider file maintenance and physician enrollment with contracted insurance payers in accordance with company policies and procedures and state and federal regulations. Assists with the development of form letters, credentialing related reports and maintenance of the credentialing database. Provides support to the Credentialing Manager and other customers as related to the credentialing and/or enrollment process.

Essential Duties and Responsibilities

· Maintain a strict degree of confidentiality in all areas relating to provider credentials, status and provider personal information.

· Review with Director of Credentialing and Medical Director prior to Credentialing Committee any adverse information regarding a provider found during the application process.

· Update expired credentials as required by policies and state and federal regulations.

· Ensure all provider enrollment paperwork is complete and submitted to the appropriate parties in a timely manner. Follow up with payers until the process is complete. Document payer ID numbers issued.

· Credential AFC and AHR physicians for all states using the appropriate state tax ID

· Provide support regarding physician enrollment to Physician Services, Revenue Cycle Management, and the Director of Credentialing.

· Maintain knowledge of all aspects of CLIA

· Maintain electronic records of provider’s credentials, work history and payer enrollments.

· Process all requests to update provider demographic or practice information and forward to the appropriate third parties as necessary.

· Communicate with Credentialing Manager regarding any or all credentialing delays or issues.

· Research state specific credentialing application and import for mapping.

Other Duties and Responsibilities

· Other duties and responsibilities or special projects as assigned.

Qualifications

Minimum of 5 years of credentialing experience, knowledge of Medicare and Medicaid and managed care. CAQH experience required. Knowledge of managed care and/or health care concepts and terminology preferred. Attention to detail. Above average interpersonal, verbal and written communication skills. High degree of organization and follow through. Thorough knowledge of Microsoft Office applications and general computer literacy.

Educational Requirements

· High school diploma or equivalency.

Physical Demands/Work Environment (optional)

Office environment. Sitting and keyboarding for extended periods of time. Frequent telephone use. High attention to detail and ability to focus. Moderate noise level.