Credentialing Specialist

This position is in Dearborn. Not remote.

Purpose:

The Credentialing Specialist is responsible for the processing of initial credentialing, privileging, re-credentialing and re-privileging applications of health care providers, as well as processing provider enrollment applications and supporting documentation for payer enrollment and re-enrollment. The Credentialing Specialist also is responsible for coordination of insurance credentialing internally and externally. The position includes follow up on the status of applications and tracking progress on all pending applications.

The Credentialing Specialist maintains the provider files and reports, which include provider demographics, correspondence with insurance plans, status of applications and pertinent licenses and certifications. He/she has knowledge of commonly used credentialing concepts, practices and procedures to perform the functions of the job and must be detail oriented and thorough in order to ensure the complex enrollment packages are complete and correct.

Communication with providers and others within the organization is essential.

PART I: ESSENTIAL POSITION FUNCTION AND DUTIES

* Work with providers in person, by phone, fax, US mail or email to obtain provider credentialing and insurance enrollment forms and all supporting documentation.

* Maintain current and accurate data needed for the credentialing and re-credentialing process for all providers.

* Process applications for appointment and reappointment of privileges to WWFHC.

* Utilize the credentialing database and performs query, report and document generation; submits and retrieves National Practitioner Data Bank reports in accordance with FTCA and HRSA requirements.

* Conduct thorough background investigation, research and primary and secondary source verification of all components of the application file per FTCA and HRSA requirements.

* Identify issues requiring additional investigation and evaluation; validate discrepancies and ensure appropriate follow up.

* Prepare credentials file for completion and presentation to WWFHC Medical Director and Credentials Committee.

* Maintain copies of current state licenses, DEA and board certificates, malpractice coverage and any other required credentialing documents for all providers.

* Track licenses, DEA and board certificates, malpractice coverage expirations for appointed WWFHC providers.

* Respond to inquiries from other healthcare organizations regarding credentialing and privileging issues as they arise.

* Maintain Credentialing and Privileging data required by FTCA for Licensed Independent Providers and Other Licensed Providers at Western Wayne Family Health Centers for annual submission to FTCA.

* Work with credentialing specialists, contracting departments, network management and provider representatives at the insurance plans to assist in a timely enrollment process, providing additional information as required by the individual plan.

* Follow up with providers to ensure that all necessary information is received and that the enrollment process is completed timely.

* Perform follow-up with insurance plans to resolve provider enrollment issues and obtain provider participation status.

* Perform tracking and follow up to ensure provider enrollments are approved and linked to the appropriate group entity and location in a timely manner.

* Maintain documentation and reporting regarding provider enrollments in process.

* Maintain up-to-date insurance files with applications, acceptance letters, provider numbers and completed provider enrollments.

* Retain detailed and accurate lists of insurance plans in which providers participate and their effective dates with each plan.

* Communicate with providers, staff members regarding each provider's participation status in insurance plans.

* Send updated list of providers and their effective status with insurance plans regularly to staff as needed.

* Notify insurance plan representatives of a provider's change in status or when a provider leaves WWFHC.

* Re-credential providers as required by individual insurance plans.

* Scan provider documents and store electronically in provider database.

* Complete quarterly updated demographics information to Managed Care Insurances per CMS requirements.

* Performs other duties as assigned.

PART II: CLINIC WIDE RESPONSIBILITIES

* Customer Relations:

* Treats guests, patients, physicians, and other employees with care, courtesy, and respect.

* Responds quickly and appropriately to customer requests.

* Looks for and suggests ways to better meet customer needs.

* Answers clinic communications systems promptly and with courtesy and respect.

* Teamwork:

* Works cooperatively within own department and other areas.

* Willingly accepts additional responsibility - tries to make others job easier.

* Responds quickly to request for assistance.

* Required to work closely with patients and associates.

* Interacts with other departments on problem issues.

* Accepts feedback from patients, visitors, clinic…