Credentialing Specialist

The Credentialing Specialist is primarily responsible for activities impacting facility and practitioner external provider enrollment and credentialing; this includes all network application and maintenance processes that impact facilities and applicable practitioners employed or contracted by Rogers Memorial Hospital, Inc.

In all activities, the Credentialing Specialist must remain aware of and comply with legal, regulatory, and financial policies and procedures. The Credentialing Specialist is in regular contact with payer strategies, medical office staff, financial services, physicians/ practitioners, and contracted payer staff. The Credentialing Specialist is responsible for maintaining up-to-date file information on payer enrolled practitioners in multiple systems, answering inquiries regarding a provider’s network status, and collaborating with colleagues to ensure the accuracy of facility contracted networks and affiliations.

The candidate must live in one the following states: WI, CA, GA, FL, MN, IL, CO, PA, TN, or WA

Job Duties & Responsibilities:

Provider Enrollment Application Processing

• Maintain understanding of RBH Privacy Practices, HIPAA, Medical Staff standards, state and federal= requirements, and other applicable corporate and departmental policies.
• Responsible for facility and practitioner enrollment activities, maintaining up to date file information in multiple systems, answering inquiries related to network status, collaborating with colleagues to ensure accuracy of facility contracted networks and affiliations
• Recommend policy and procedural updates as applicable
• Maintain standard outreach to on-boarding medical staff providers detailing initial and ongoing provider= enrollment requirements
• Maintain knowledge of all data and document locations required as part of the enrollment process
• Maintain knowledge of standard work detailing contracted payer provider credentialing processes for all exclusive contracts.
• Communicate accurate RBH location and demographic information
• Populate and maintain both facility and provider level information in the CAQH system
• Enroll and maintain facilities and practitioners in all appropriate contracted health plans
• Enroll practitioners with government payers using electronic application methods such as PECOS and portals
• Populate credentialing software with timely and accurate provider status and affiliation information
• Monitor and disseminate affiliation, application and revalidation status upon request and as applicable
• Maintain privacy and confidentiality at all times.

Payer Strategies_ Internal

• Establish and maintain positive and cooperative working relationship with Payer Strategies team
• Remain aware of contractual adjustments that may impact provider affiliations and/or payment

Patient Financial Services _ Internal

• Establish and maintain positive and cooperative working relationship with all Patient Financial Services team= professionals
• Populate and maintain Symplr Provider information referenced by PFS staff to investigate and appeal= professional claim denials
• Establish and provide ongoing assist with PFS staff Symplr Provider logins

Contracted Payer Groups _ External

• Regular written and verbal communications with payer group representatives at multiple levels
• Respond to all applicable payer outreach for information and/or clarification

Other Duties and Responsibilities

• Complete projects as assigned by Credentialing Manager
• Regular assistance with and dissemination of payer communications impacting other departments
• Participate in process improvement events and activities
• Serve as a back-up to other Payer Strategies positions on an as-needed basis.
• Assist in promoting a team atmosphere by treating individuals with respect and honesty and by using direct= communication and active listening skills.

Additional Job Description:

• Associate’s degree or 2 years' experience
• Administrative skills, including computer/word processing
• Computer proficiency, adaptability and working knowledge of Microsoft Office, Adobe and Excel
• Exceptional critical thinking skills and sound judgement
• Exceptional written, verbal, and auditory skillset
• Ability to perform all essential job functions either on site or remotely

Qualifications / Preferred:

• Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards
• General understanding of health insurance plans, provider enrollment processes, payer contracting and remittance processes, and HIPAA and healthcare compliance
• Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment
• Symplr Experience
• Experience with CAQH (Council for Affordable Quality Healthcare) database and application process
• Prior professional history in a medical or mental health setting
• NAMSS/CPCS Certification

With a career at Rogers, you can look forward to a Total Rewards package of benefits, including:

• Health, dental, and vision insurance coverage for you and your family
• 401(k) retirement plan
• Employee share program
• Life/disability insurance
• Flex spending accounts
• Tuition reimbursement
• Health and wellness program
• Employee assistance program (EAP)

Through UnitedHealthcare, UMR and HealthSCOPE Benefits creates and publishes the Machine-Readable Files on behalf of Rogers Behavioral Health. To link to the Machine-Readable Files, please visit Transparency in Coverage (uhc.com)