GENERAL SUMMARY:

Under general supervision, maintains close communication with providers, practice managers and the medical staff office to ensure timely initial credentialing, recredentialing and reappointments through the different entities, Credentials Committee and Board of Directors Meetings.

DUTIES AND RESPONSIBILITIES:

Processes initial provider enrollment with payers, initial credentialing and recredentialing:

1 Creates, assembles and prepares application packet for providers to complete, reappointment applications for WellSpan Health entities and submits applications to payers. 2 Completes primary source verifying provider credentials per established policies and procedures. 3 Enters provider credentials and application requirements into Cactus, CAQH. 4 Initiates mandated queries, both federal and state, for all initial applicants and those due for recredentialing with the National Practitioner Data Bank. 5 Adheres to all policies and procedures regarding mandated queries and reporting mechanisms. 6 Maintains close communication with provider, practice managers, medical staff office, insurance reps, locum tenens agencies, office administrators to ensure timely credentialing through the different entities. 7 Reviews and conducts QA checks on the applications prior to medical directors review. 8 Reattests provider information every 120 days in CAQH. 9 Runs reports and complete Medicare and Medicaid revalidations for WellSpan Medical Group (WSMG) & Hospital Based providers. 10 Maintains confidentiality of provider information. Data Management 11 Follows up, receives and documents confirmations on all initial enrollment status and changes for health plan providers with which WellSpan participates. 12 Runs weekly Credentialing Update reports to IS Department for billing system update. 13 Runs expiring provider credentials reports, notifies practices and updates Cactus accordingly. 14 Assists with helping resolve claim issues by contacting applicable provider reps. Change letters 15 Creates and submits letters to update payers, Cactus, CAQH, NPI and other stakeholders of any changes and terms to provider data per 25 payer requirements. DEPARTMENT DESCRIPTION:

WellSpan Population Health Services provides coordination of health benefits offering a Preferred Provider Organization supporting accountable care and medical management which includes case management and utilization management. WellSpan Population Health Services is committed to provide care in compliance with the WellSpan triple aim: to improve the cost, quality, and patient experience in an efficient and effective delivery system for patients and providers.  

Required Skills Required Experience

MINIMUM EDUCATION:

High School or G.E.D.

PREFERRED EDUCATION:

Associate’s Degree

MINIMUM EXPERIENCE:

2 - 3 years

PREF FIELD OF EXPERTISE:

Hospital/physician office/insurance claims; credentialing experience

PREF CERT/REGISTRATION:

National Association of Medical Staff Services (NAMSS) Certification as a Certified Provider Credentialing Specialist (CPCS)