- Administrative/Accreditation Duties:
- Researches and processes new health plans applications for Center and its providers.
- Manages health plans enrollments, increasing plan acceptance/participation for Center and all providers using applicable software (i.e. OneApp Pro)
- Provides consistent, accurate, and timely credentialing support for Center's accreditation process.
- Acts as coordinator for furthering any and all Center's wide certifications it may decide to pursue.
- Acts as internal resource around issues associated with public funding sources, such as Medicaid and Medicare, as well as private payors.
- Ensures Center and its providers take advantage of all the existing incentive initiatives through Medicaid and Medicare with the submission of the appropriate application
- Provides accurate, timely and documented verification of the information provided by new applicants as well as current providers.
- Assists with the onboarding process of medical, dental and behavioral health services providers.
- Verifies, researches, and responds to telephone and written inquiries from providers and other departments, pertaining to provider participation and credentialing status.
- Works with medical and finance staff to ensure list of all current payers sorted by the number of patients within each group and all insurance carriers sorted by the type of product (Medicaid, Medicare, or CHIP), patient copay and fee schedule are kept and updated regularly.
- Regularly communicates to medical and finance staff on all health plans enrollments and updates.
- Coordinates all additions, terminations and changes to all plans as appropriate.
- Prepares and maintains reports on all accreditation and credentialing activities as required,
- Supports development (writing), implementation and upkeep of all Center's policies and procedures as needed.
- Assists to maintain Center's specialty care network.
- Quality Assurance/Credentialing Duties:
- In conjunction with Human Resources (HR) maintains compliance with documentation standards for verification of employee credentialing requirements, including but not limited to, licenses, certifications, registrations, permits, educational degrees, internship, residency and association memberships and any related electronic systems and software.
- In coordination with HR, ensures all required backgrounds and re-verifications are performed during hiring and thereafter. (i.e. National Practitioner Data Bank).
- In coordination with HR, ensures all records are properly kept for all providers (i.e. the National Practitioner Data Bank, CAQH, and the Utilization Review Accreditation Commission).
- Collects, enters and ensures data in the CAQH Universal Provider Data Source are updated.
- Participates in site visit(s) for credentialing purposes as well as programmatic audits as required.
- In conjunction with the Compliance Associate, ensures Center's credentialing process fully complies with HIPAA and Joint Commission.
- Ensures that on-line trainings are current as required (MyLearningPointe and other trainings).
- Safety:
- Participates in all safety programs which may include assignment to an emergency response team
- Acts upon assigned role in Emergency Code System
- Ensures proper hand washing according to Centers for Disease Control and Prevention guidelines.
- Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice
- No supervisory responsibilities.
- Minimum two years of experience managing credentialing, privileging, or similar healthcare professional verification and organization's accreditation processes are required.
- Minimum 1 year of experience in health plan enrollments and management is required
- Experience in insurance management is highly preferred.
- Credentialing Specialist (CPCS) preferred.
- Principles of effective analysis and highly effective writing.
- Principles and practices of health care systems and medical administration.
- Skill in operating phones, personal computer, software and other IT systems.
- Skill in oral communication
- Ability to communicate with employees, patients and other individuals in a professional and courteous manner.
- Ability to pay close attention to detail and to ensure accuracy of reports and data.
- Fluent in English and Spanish
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Specialist, Credentialing - Miami, United States - Cano Health
Description
It's rewarding to be on a team of people that truly believe in making an impact
We are committed to building the best primary care environment for patients and are seeking healthcare enthusiasts to join us.
Job Summary
The Credentialing Associate is responsible for all aspects of the privileging and credentialing process for all licensed clinician/providers of the center (i.e. physicians, physician assistants, ARNPs, dentist, dental hygienist, clinical counselors, etc.). In addition, this position is responsible for all communication leading toward insurance panel accreditation for staff and center.
Duties & Responsibilities
Essential Duties & Responsibilities
Physical Requirements
This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Travel Requirements
Travel Required
Amount of Expected Travel
Details
Work will involve some driving/traveling to assigned clinics.
Tools & Equipment Used
Computer and peripherals, standard and customized software applications and tools, and usual office equipment.
Disclaimer
The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.
Join our team that is making a difference
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