Jobs

16/08/2023

Description:

Position Summary

Facilitates the process of governmental enrollment and managed care insurance credentialing/recredentialing for hospital employed practitioners with all contracted insurance plans. Also facilitates the credentialing/recredentialing process for Natchitoches Regional Medical Center facilities. Oversees internal delegated credentialing audits on behalf of hospital employed practitioners. Builds and maintains positive relationships with managed care insurance/payors and serves as a central point of contact regarding managed care insurance/payor issues.

Primary Responsibilities

1. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.

2. Coordinates, monitors and maintains the credentialing/recredentialing of all practitioners employed and/or contracted. Completes and sends managed care and governmental applications to practitioner for signature, and coordinates the signing of the applications with the delegated/authorized official. Also completes credentialing/recredentialing applications on behalf of Natchitoches Regional Medical Center facilities.

3. Follows up with managed care organizations and governmental programs regarding credentialing status and provider numbers. Responsible for maintaining the accuracy and integrity of the credentialing database.

4. Generates and oversees the distribution of reports for delegated agreements. Coordinates and oversees the internal delegated credentialing audits which include generating reports, preparing files for audit review and tracking & monitoring the audit outcome.

5. Independently handles requests, for additional information, from managed care organizations & governmental programs. Also identifies and responds pro-actively to issues and concerns regarding practitioner set up.

6. Notifies managed care organizations and governmental programs of provider changes (such as, address changes, terminations, etc.). Provides oral and written follow-up to the managed care organizations and governmental programs to confirm the changes have been made. Generates and distributes provider number reports upon request. Constantly seeks out ways to improve communication and the flow of information to our internal and external customers.

7. Performs other related duties as required Performs other duties as assigned.

8. Tracks and monitors the credentialing/recredentialing process of managed care organizations and governmental programs, and works closely with these payors in order to expedite the credentialing/recredentialaing process to ensure that practitioners are being credentialed and added to provider networks.

9. Works closely with internal finance and service line customers along with internal/external billing groups to resolve credentialing and outstanding Accounts Receivable/revenue issues. Conducts monthly/bi-monthly meetings/calls with internal customers and internal/external billing groups to ensure continued communication and timely resolution of outstanding billing, payment & provider enrollment issues.

10. Works directly with practitioners, service line leaders, practice administrators and hospital executives to initiate the credentialing/recredentialing process. Partners with Medical Staff offices and Executive Administration on new service line initiatives.

11. Works pro-actively with managed care organizations and governmental programs to stay current on policies and regulations governing credentialing/enrollment/plan participation. Educates internal customers on relative updates & changes and impact on relative business operation

Competencies

1. List competencies

2. Use as many numbers necessary

Supervisory Responsibility

None.

Requirements:

Required Education and Experience

1. Bachelor’s degree preferred (or equivalent work experience) in business, or related health care discipline. Extensive knowledge of managed care enrollment and contracting procedures.

Preferred Education and Experience

1. 5 years of health care experience in managed care and governmental credentialing, payor relations and physician relations including experience working for a managed care insurance plan. Experience with practitioner and facility credentialing process, and experience completing managed care and governmental credentialing applications. Customer service and managed care contract experience preferred.

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