PURPOSE STATEMENT:

The primary duty of the Credentialing Specialist is to provide support and guidance to assigned facilities in all areas of the credentialing portion of the managed care/contracting process. They will partner with facilities to assist in the preparation of the proper documentation for submission to meet the deadlines required. They will also assist in the review of paperwork for Medicare, Medicaid, and commercial payer compliance of documents for the organization. Credentialing Specialist maintains the department work flow to ensure accuracy and completion of tasks in a timely manner.

ESSENTIAL FUNCTIONS:

1. Assist in the preparation of applications for physician and facility participation in payer programs, including Medicare 855A, 855B, 855I and 855R and similar applications for Medicaid programs and managed care plans.
2. Track and monitor facility entries in Medicare’s PECOS database.
3. Assist facility credentialing leads in the preparation of Disclosure of Information documents requiring corporate validation and signature.
4. Prepare and submit initial state Medicaid enrollments and re-validations.
5. Prepare and administer facility information to the NPPES website. This will include initial NPI for new facilities, edits to existing NPIs, and Group NPI’s for physician billing.
6. Work closely with Corporate Director of Managed Care to ensure efficiency of processes and create new work flow tools as needed.

OTHER FUNCTIONS:

• Perform other duties as assigned.

STANDARD EXPECTATIONS:

• Complies with organizational policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality.
• Communicate clearly and effectively to all stakeholders.
• Develops constructive and cooperative working relationships with others and maintains them over time.
• Encourages and builds mutual trust, respect and cooperation among team members.
• Maintains regular and predictable attendance.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• BA/BS degree preferred but not required.
• One - three years of healthcare experience is required.
• Basic to working knowledge of managed care concepts.
• Documentation, proficiency, attention to detail, and organization skills are essential.
• Excellent communication skills, especially written, and the ability to concisely summarize
• Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
• Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
• Self-motivated with strong organizational skills and superior attention to detail.
• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames.  Ability to adapt to frequent priority changes.
• Capable of working within established policies, procedures and practices prescribed by the organization.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Not Applicable

SUPERVISORY REQUIREMENTS:

This position is an Individual Contributor

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances
(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

AHCORP

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