Job Title: Credentialing Specialist
Reports To: Chief Human Resources Officer
Program: Human Resources
Location: Tarrytown or Remote (but willingness to be on site for MCO visits if necessary)
Hours Per Week: 21
FLSA Status: Non-exempt
Salary Range: $22/hr - $28/hr
Summary Description: The Credentialing Specialist will support the administrative process of maintaining provider files, tracking expirations, reviewing and completing applications, data entry, verifying healthcare providers’ qualifications, ensuring compliance with regulatory and organizational standards including federal, state and organizational policies. This is done for both new hires and re-certifying existing hires.
Key Responsibilities:
Provider Credentialing & Licensing:
- Manage the credentialing and recredentialing process for all licensed (SW, LMHC, MD, PNP, etc) and unlicensed providers (CASACs, peers, etc).
- Manage Council for Affordable Quality Healthcare (CAQH) for providers that are enrolled.
- Ensure all providers maintain current licensure and certifications and maintain a live credentialing spreadsheet with all of this information.
- Track upcoming expirations and reach out to staff when their license or certifications are expiring 60 days and 30 days before expiration.
Payer Enrollment (Medicaid/Medicare & Commercial Plans):
- Complete and submit applications for enrollment and revalidation with Medicaid, Medicare, and commercial insurance plans.
- Complete quarterly rosters for Managed Care Organizations (MCOs).
- Monitor the status of enrollment applications and follow up to ensure timely approvals.
- Troubleshoot and resolve any enrollment issues or delays that impact billing.
Site Credentialing & Facility Enrollment:
- Coordinate and submit all documentation required for facility/site credentialing with payers and accreditation bodies.
- Maintain compliance with site-specific credentialing standards and renewals.
- Prepare for and support audits related to facility credentials and compliance.
- Attend any site credentialing site visits.
MCO Liaison:
- Serve as the primary point of contact for MCOs
- Facilitate communication between the agency and MCOs to ensure credentialing compliance and resolve any issues.
- Attend MCO meetings and stay up-to-date on policy and procedural changes.
Billing & Revenue Cycle Support:
- Collaborate closely with the billing team to ensure provider credentials and enrollments are accurately reflected in payer systems. Work with EHR System Administrator at time of staff hire to ensure credentials are in NetSmart.
- Support the resolution of claim denials related to credentialing or enrollment.
- Ensure provider billing privileges are active and current with all payers.
Miscellaneous:
- Sit on CBHS' credentialing committee and attend all meetings.
Key Competencies:
- Must be extremely organized, flexible and able to prioritize
- Must demonstrate effective communication skills and the ability to work successfully with a wide range of people, often under challenging circumstances
- Must be discreet and maintain confidentiality
- Must be able to work with complicated websites and portals and take detailed notes for future use
- Ability to work in a fast-paced, deadline driven setting
Key Performance Indicators (KPIs):
- Accuracy in data entry and analysis related to credential of new and existing staff
- Success rate in obtaining and maintaining up-to-date billing and Medicaid/Medicare credentials for clinical and medical staff
- Enroll new providers and social work staff before deadlines
- Reach out to staff for recertification and credentialing before current status expires
Requirements:
- Associate’s degree required; Bachelor’s degree in a related field preferred.
- Minimum 3 years’ experience in an administrative role or 1 – 2 years in a medical office. Credentialing experience preferred.
- Excellent verbal, written, interpersonal and customer service communication skills
- Excellent organizational skills and attention to detail
- Ability to work independently
- Proficiency in Microsoft Office suite and database management systems, and credentialing software (CAQH, PECOS, NPPES) a plus
- Fluency in English (Reading, Writing, Speaking).
- Must be cleared and maintain clearance by applicable regulatory clearances as required.
- Legally eligible to work in the United States without sponsorship.
Special Considerations:
- Hours per week, reporting structure, and location are subject to change per program needs.
- May be sitting and/or performing computer work for extended periods of time.
Mandated Reporter:
This is a Mandated Reporter position. The NYS Justice Center legislation defines anyone who has regular and substantial contact with any person with special needs as a “custodian” under the law and, therefore, a mandated reporter. You can be held liable by both the civil and criminal legal systems for intentionally failing to make a report.
Greater Mental Health of New York is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, or genetic information. Greater Mental Health of New York is committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. To request a reasonable accommodation, contact the Human Resources Department.