Medical Insurance Data Entry

GENERAL DESCRIPTION:

Responsible for soliciting, collecting, and validating documents necessary for the credentialing and re-credentialing of participating healthcare professionals and facilities in the provider network for all company lines of business, following the requirements of Industry regulatory agencies, Credentialing policies, and procedures.

ESSENTIAL FUNCTIONS:

• Receives, prints, stamps, and digitizes all documents received from providers by mail, fax, e-mail, or hand delivered, as state and federal regulatory agencies require.
• Evaluate information to ensure strict compliance with credentialing processes according to accrediting agencies and regulatory standards.
• Performs primary and secondary validations against the provider's credentials using Federal and State databases.
• Performs primary validations such as NPDB (National Practitioner Data Bank) reports, education validations, Board validations, grievances, Medicare OPT-OUT, CMS PRECLUSION LIST, EPLS (Excluded Parties List System), and OIG (Office of Inspector General).
• Evaluate the credentialing file and assign the Level I or II category for presentation to the credentialing committee.
• Verifies and documents expiring credentials, using acceptable verification sources to ensure compliance with accrediting agencies and regulatory standards.
• Researches and validates discrepancies and/or adverse information obtained from the application, primary source verification, or other sources to ensure that each file has all the necessary information for the Credentialing Committee's evaluation and approval process.
• Continuously and consistently modifies and updates provider credentials, and demographic data in the Credentialing System.
• If required, physically inspect medical offices and facilities to complete the required credentialing and recredentialing processes as needed.
• Documents the entire process in the Credentialing system, including specific documentation of all follow-ups, process progress, and pending documentation. Provides necessary follow-up to complete the process for providers following the Credentialing Policy. In the case of Providers that represent a risk due to the impact on membership, alert the management to seek other contact or contracting alternatives that minimize the impact.
• Receives, reviews, and guides providers personally or by telephone on the credentialing and re-credentialing process, the status of applications, and/or pending documents, among others.
• Prepares, maintains, and updates provider credentialing files for evaluation by the Credentialing Committee.

Education and Experience:

Associate's degree or at least sixty to sixty-four (60-64) college credits. At least one (I) year of experience performing duties in similar positions of monitoring and reporting areas, preferably in the Healthcare Insurance industry.

Other: Availability to work extended hours, weekends, and holidays as per the operations requires. The employer requires this work be done in person.

Languages:

Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

SKILLS, ABILITIES & KNOWLEDGE:

• Customer Service oriented.
• Excellent organizational.
• Ability to work collaboratively with colleagues and staff to create a results-driven, team-oriented environment.
• Able to use all related hardware and software (Word, Excel, PowerPoint, Outlook)
• Ability to manage priorities and workflow.
• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm.

TPIS is an Equal Opportunity Employer (EEO Employer / Affirmative Action for Females / Disabled / Veterans). We comply with all Federal, State and Local laws regarding nondiscrimination.

Job Type: Full-time

Pay: From $12.00 per hour

Work Location: In person