- Coordinates the enrollment/credentialing and reenrollment/recredentialing process as outlined by the rigorous guidelines for third party payor physician enrollment, according to NCQA and other regulatory guidelines.
- Manages the Payer revalidation process, specifically focusing on Medicare/Medicaid. Functions as a team member to work closely with the Provider Enrollment Relations Manager to ensure seamless coordination of activities. Evaluates physician enrollment/credentialing documentation regarding the criteria as established by the National Committee for Quality Assurance (NCQA).
- Generates monthly Echo audit reports for Medicare sanctions and opt-out cases.
- Maintains a functional relationship between the physician group and the various third-party payors via excellent verbal and written abilities.
- Cultivates and sustains effective communication between the physician group and multiple third-party payors through exceptional verbal and written communication skills.
- Coordinates delegated enrollment/credentialing audits and site/medical chart reviews performed by third party payor representatives.
- Arranges in-services and training for the operations staff with various third-party payors.
- Facilitates the dissemination and comprehension of information provided by third-party payors related to insurance billing. Distributes and assists in the interpretation of information from the third-party payors, pertinent to the insurance billing process.
- Updates and distributes the monthly roster for all third-party payers ensuring pertinent data fields have been populated for New Physicians and Terminations.
- Coordinates and directs the monthly New Provider onboarding.
- Maintains a master physician database and updates CAQH Proview and Availity applications. Monitors practitioner NPPES status and conducts outreach to ensure accuracy.
- Maintains databases and practice management systems utilized by the organization.
- Manages a third-party payor reference library with provider manuals and directories.
- Acts as the liaison between physician, facility, and third-party payor.
- Monitors the initial reenrollment/reappointment and expirable process for all medical staff, and delegated providers, ensuring compliance with regulatory bodies (Joint Commission, NCQA, CMS, federal and state), as well as Medical Staff Bylaws, Rule and Regulations, policies and procedures, and delegated contracts.
- Handles inquiries from healthcare organizations and collaborates with both internal and external stakeholders to address daily enrollment, credentialing, and privileging issues in a timely manner.
- Recognizes issues necessitating further examination and assessment, verifies discrepancies, and ensures thorough follow-up procedures are executed.
- Enhances operational efficiency by executing query, report, and document generation tasks, and proficiently submits and retrieves database reports in compliance with the Health Care Quality Improvement Act.
- Participates in special projects, as needed, to maintain files and records.
- Advanced knowledge of related accreditation and certification requirements.
- Skilled in effectively using databases, including crafting queries, generating reports, and creating documents with ease.
- Intermediate user of personal computers, applications, and Microsoft Office software.
- Proficient in utilizing and accessing provider dictionaries such as NCQA, NPPES, and CAQH.
- Ability to utilize critical thinking skills to problem solve and make procedural decisions.
- Ability to exercise discretion and ensure a high-level of confidentiality.
- Ability to communicate effectively verbally and in writing with varying levels internal and external to the organization.
- Demonstrates proficiency in fostering and sustaining positive and collaborative work relationships with faculty, staff, students, and members of the public.
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Provider Enrollment Specialist - Washington, United States - Howard University
Description
The Talent Acquisition department hires qualified candidates to fill positions which contribute to the overall strategic success of Howard University. Hiring staff "for fit" makes significant contributions to Howard University's overall mission.
BASIC FUNCTION:
The purpose of this position is to act as the liaison between the Faculty Practice Plan, the physician group, the hospital, and the various insurance carriers. Incumbents typically work at a high degree of independence with general direction and supervision received from a department supervisor, manager, assistant/associate director or assistant/associate dean.
SUPERVISORY ACCOUNTABILITY:
Responsible for coordinating, and administering the payer enrollment process, ensuring its effectiveness and compliance with relevant accrediting and regulatory standards. This includes initial enrollment, reenrollment, and managing expirables. Maintains up-to-date knowledge of relevant statutes and laws pertaining to credentialing, while ensuring adherence to applicable regulations.
NATURE AND SCOPE:
Internal contacts may include senior administrators, staff, faculty, students and staff. External contacts may include payers, vendors, consultants and the general public.
PRINCIPAL ACCOUNTABILITIES:
Bachelor's Degree in related field and 1-3 years of general work experience. 8 years of related work experience may be substituted in lieu of educational qualifications.
