Commercial Enrollment and Credentialing Specialist

Job Summary:

Under the direction of the Manager of Commercial Enrollment and Credentialing, the Credentialing Specialist position is responsible for assisting the Payor Relations team in regard to managing the paperwork flow/document retention for the payor enrollments, credentialing and re-credentialing. This position will also support the Credentialing Manager for assistance with new Medicare and Medicaid enrollments.

Duties/Responsibilities:

Acts as the internal contact for managing the documentation needed in the completion of payer applications, contract requests, and credentialing/re-credentialing requirements.

• Credentialing File Maintenance
• Twice a month emails are sent to the franchise for any expiring license, bonds, accreditations, and insurance. Keeping each franchise file up to date and Integrated Services system.
• Initial Credentialing
• Assist with initial document submission for Commercial payors; to include Managed Medicaid and Managed Medicare submission.
• Re-credentialing and Revalidations
• Assist with Managed Care contracts, including National contracts re-credentialing using their forms or online website.
• PBM Re-credentialing
• Franchise Change
• Change of address, ownership, bank account, new Tax ID, or anything related to a change for Franchise or Clinic.
• New Payer Enrollments.
• Other tasks/projects as assigned.
  
  

Required Skills/Abilities:

• Must have experience applying for Facility/Provider NPI using the NPES website.
• Strong knowledge of NCPDP preferred.
• Must have strong knowledge of the Medicare PECOS website for enrollment, re-validations, and change of information.
• Knowledge of multiple payers and what they require for credentialing, re-credentialing, contracting, etc.
• Must have strong verbal and written communication.
• Be a self-starter who is accountable and requires minimal direction and supervision; a person who is open to new ideas; and a creative and flexible individual who is comfortable working in a fast-paced, large, complex organization.
• Possess the personal characteristics of professionalism, credibility, commitment to high standards, innovation, discriminating judgment, and accountability.
• Solid understanding of contract terms, fee schedule, and credentialing/re-credentialing with payers.
• Demonstrated ability to operate collaboratively as part of a team.
• Must demonstrate strong written/verbal communication skills.
• Must be a highly self-motivated individual with the ability to function in a fast-paced environment under minimal supervision and direction.
• Must be able to handle multiple tasks and priorities.
• Must be able to effectively translate between a health plan and provider communities.
• Must be a dedicated team player with the willingness to desire to learn and grow within the organization.
• Working knowledge of MS Outlook, Word, and Excel.
  
  
  

Education and Experience:

• High School Diploma, Associates Degree.
• A minimum of three years credentialing experience with emphasis on Facility Credentialing/Contracting and provider enrollment.