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Credentialing Specialist

People's Health Centers | St. Louis, MO | Full Time

Job Description

Work at a fast-paced, thriving company serving a diverse St. Louis population! We offer competitive benefits, compensation, and an outstanding reputation in the community.

Position Summary

The Provider Enrollment and Credentialing Specialist is responsible for the credentialing and re-credentialing of all licensed or certified health care practitioners and the completion of provider applications and follow-up to enroll and disenroll the health center’s Licensed Independent Practitioners (LIP’s) with Medicare, Medicaid, and accepted commercial health insurance plans, including key managed care plans.  This role requires credentialing and recredentialing to be processed in an accurate and timely manner in accordance with the standards of the health center, its contracted organizations and its governing agencies in order to ensure that the health center will be reimbursed for the services rendered by the practitioners at each practice location. This position will report to the Director of Credentialing.

Duties and Responsibilities:

  • Conduct and document credentialing/re-credentialing for the health center’s licensed, certified, or registered health care practitioners.
  • Complete and submit provider enrollment and credentialing applications for LIP’s which meet deadlines that facilitate initial enrollment effective dates prior to or close to a provider’s hire date or meet re-credentialing due dates.
  • Facilitate Missouri Health Plus credentialing.
  • Expedite the completion of credentialing applications applying an understanding of specific requirements for applications and forms, supporting documentation, practitioner licensing, training and certification, and health plan participation and performing the proper completion of forms and collection of required supporting documentation and signatures.
  • Complete the credentials verification process in a manner which ensures compliance with the standards of the health center’s credentialing policies and procedures HR 1500.10, HR 1500.17, and HR 1500.02, HRSA PIN 2002-22, CMS, The Joint Commission, health center contracts and arrangements, and regulatory agencies.
  • Manage CAQH Proview provider database as required, including setting up new provider accounts, managing the Practice Administrator database to assist with set up for new provider accounts, and maintaining the appropriate provider updates and reattestations on existing accounts. 
  • Maintain (paper) records of completed provider enrollment and recredentialing applications in an organized manner which allows for easy referral when submission confirmation is required.
  • Maintain provider credentialing files, records, and logs; track and record provider enrollment applications, recredentialing submissions, approval effective dates, licensing updates, etc.
  • Maintain and distribute a monthly Excel report of enrollment effective dates by provider, payor type and payor.
  • Establish and maintain strong working relationships with health center staff, insurance payor contacts, and other external contacts to foster a successful outcome to the credentialing and contracting of providers.
  • Respond to internal and external inquiries regarding credentialing, enrollment, or approval.
  • Perform research, analyses, and follow-up as needed to resolve provider enrollment issues demonstrating an understanding of various provider degrees and requirements for education, training, certification, and licensing and health insurance plan participation requirements.
  • Prepare and send 60 day document reminder notices to all active LIP & OLP providers at the beginning of each month, tracking responses, filing documents, and updating credentialing records as required  (provider files, CAQH Proview, credentialing logs, hospital medical staff offices and CVO’s, insurance payors, etc.).
  • Perform OIG and SAM searches for all active LIP & OLP providers at the beginning of each month and keep record of results.
  • Prepare and submit term notification requests to the payor contacts for providers terminating employment with the health center.
  • Report monthly tasks and accomplishments at month-end in the appropriate Credentialing log in the share drive.
  • Perform other duties as assigned.
  • Maintain strict confidentiality regarding provider information.

Job Requirements:

  • Bachelor’s degree or appropriate combination of education and experience.
  • Ability to produce thorough work results with a strong attention to detail and accuracy.
  • Strong analytical and problem solving skills.
  • Excellent written, verbal, and listening skills which facilitate desired results, including the ability to compose written correspondence and effectively communicate verbally with internal and external clients.
  • Organized with good filing and recordkeeping skills.
  • Working knowledge of Microsoft Office Outlook, Word, Excel and Internet.  Typing skills.  Experience with Adobe Acrobat 8 Professional a plus. 
  • Ability to build and develop strong customer relationships with internal and external clients.
  • Ability to work in a fast paced environment, prioritize work, and change work flow priorities suddenly based upon need.
  • Ability to respond promptly and professionally to credentialing and enrollment inquiries via telephone, fax, email, or U.S. mail.
  • Ability to read and interpret written information.
  • Ability to follow directions.
  • Ability to file documents and create and utilize efficient filing systems.

People's Health Centers does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability, veteran status, military obligations, and marital status.