CREDENTIALING AND PAYOR ENROLLMENT SPECIALIST

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Department Duties

* Responsible for timely and accurate submission all initial hospital credentialing and payor plan enrollment for incoming providers

* Responsible for timely and accurate submission all hospital recredentialing and insurance plan reenrollment for existing providers

* Establish and maintain a database of all dental providers with complete credentialing and IPA information

* Serve as liaison between the providers and CMO and insurance offices. Proactively address any issues including missing documentation with providers

* Work closely with CMO and Dental Staff personnel to provide first line quality assurance in the processing of dental staff credential and re-credential applications in accordance with their regulations and requirements

* Attend and participate in CMO provider relations meetings

* Keep management informed early in the process of any delinquent or uncooperative providers

* Maintain confidential providers files in accordance with The Joint Commission requirements. Ensure documents with expiration dates are up-to-date, and follow-up with providers around renewals(i.e. license registration, DEA, board certifications etc)

* Maintain and update CAQH/ ADA Attestations for all eligible providers

* Manage and maintain taxonomy codes for all providers

* Process resignations and change of status with the CMO for all providers

* Attain qualification as a Notary Public

Qualifications

• High School diploma/ GED Required

• 1-3 years Hospital credentialing Required

• 1-3 years Insurance plan (Commercial, Medicaid, Medicare, and Medicaid/ Medicare Managed Care) enrollment Required

• 1-3 years dental credentialing and insurance plan enrollment Preferred

• Ability to work effectively with co-workers as a team member

• Ability to multitask in a fast paced environment

• Ability to work independently with minimal supervision

• Strong Interpersonal, oral, and written communication skills with excellent self-discipline and patience between payors, providers, physicians, and colleagues

• Identifies, analyzes, and resolves extraordinary information, discrepancies, time gaps, and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners discovers and conveys problems to Credentialing Manager

• Proficient computer software and database skills