Payor Credentialing Specialist (remote)

Job Description

Job Description

Remote Position - Requires Payor Credentialing and Payor Enrollment experience

The Payor Credentialing Specialist is responsible for leading, coordinating, monitoring, and maintaining the payor and provider credentialing and re-credentialing processes. Facilitates all aspects of BHG’s payor credentialing including payor enrollments, revalidations, maintenance, license updates, and follow up on payor credentialing related A/R issues. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to payor credentialing and enrollment. Responsible for the accuracy and integrity of the credentialing database system and related applications. Works under the supervision of the Director of Payor Credentialing in conjunction with Chief Revenue Officer.

The key responsibilities of the Payor Credentialing Specialist include but not limited to:

Duties and Responsibilities

• Prompt and regular attendance at an assigned work location.
• Ability to complete or oversee the completion of assigned tasks/projects in a timely manner.
• Complete process to enroll and credential facilities as well as providers with insurances; ensure all payor criteria are met.
• Leads, coordinates, and monitors the collection, review, and analysis of payor enrollment applications.
• Responsible for accuracy and completeness of payor enrollment submissions including supporting documentation.
• Follow up with providers and insurances for timely credentialing and enrollment process(es).
• Responsible for monitoring application progress and following up with payors as needed until confirmation of credentialing and network load is complete.
• Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow-up.
• Review, and update if necessary; health plan directories, agencies, and other appropriate entities for current and accurate provider information
• Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and enrollment issues as they arise.
• Utilizes the credentialing database, optimizing efficiency, and performs query, report and document generation.
• Enters and maintains accuracy of data input into Credential Stream, PECOS, NPPES, CAQH, Optum, Availity, and other payor portals.
• Verify provider accuracy in payor directories.
• Provide support with managed care delegated credentialing audits; conduct internal file audits.

Regulatory

• Ensure compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state laws) and policies and procedures in all aspects of the payor credentialing process.

Marketing and Outreach

• Participate in community and public relations activities as assigned.

Professional Development

• Demonstrates the belief that addiction is a brain disease, not a moral failing.
• Demonstrates hope, respect, and caring in all interactions with patients and fellow team members.
• Establishes and maintains positive, professional relationships in the workplace.
• Ability to work independently and under deadlines while handling multiple tasks simultaneously.
• Makes decisions and uses good judgment with confidential and sensitive issues.
• Maintain professional, calm demeanor with others in stressful or other undesirable situations.

Training

• Attend and complete all required trainings as assigned by Director.
• Prompt and regular attendance at an assigned work location.

Minimum Requirements

• The Credentialing Administrator needs at least 3 to 5 years of experience in payor credentialing/enrollment experience.

Qualifications

• Bachelor’s degree preferred or comparable work experience.
• Current CPCS or CPMSM certification or working towards certifications.
• Experience or working knowledge of full credentialing cycles; initial payor credentialing/enrollment, maintenance and revalidation.
• Experience or working knowledge of CredentialStream credentialing platform or other credentialing database software.
• Excellent attention to detail, problem-solving, critical thinking, and analytical skills.
• Strong working knowledge of word processing, spreadsheets, data entry, database experience and other computer related skills.

In addition to meeting the qualifications, the ideal candidate will embody the following characteristics and possess the knowledge, skills and abilities listed below:

• Holds a basic understanding of substance use disorder.
• The highest ethical and professional standards.
• Maintains the strictest confidentiality.
• Excellent written and verbal communication skills.
• Excellent attention to detail and problem-solving skills required.
• Excellent analytical, judgment, and decision-making skills.
• Proficient in Adobe, Excel, PowerPoint, Word, Outlook, and other Microsoft Office applications.
• Well organized, capable of juggling multiple projects and accustomed to tight deadlines.
• Ability to work effectively and independently with both clinical and non-clinical colleagues.
• Ability to perform research independently.

Physical Requirements and Working Conditions

The physical demands described here are representative of the requirements that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions to the extent such accommodation does not create an undue hardship on the business.

• Speaking and hearing ability sufficient to communicate effectively by phone or in person at normal volumes
• Vision adequate to read correspondence, computer screen, forms, etc.
• Sit for long periods of time, some bending, stooping and stretching
• Variable workload, periodic high activity level
• Keyboarding for long periods of time

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by team members assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of team members so classified. All team members may be required to perform duties outside of their normal responsibilities from time to time, as needed, and this job description may be updated at any time.

BHG is an equal opportunity, affirmative action employer providing equal employment opportunities to applicants and employees without regard to race, color, religion, age, sex, sexual orientation, gender identity/expression, national origin, protected veteran status, disability status, or any other legally protected basis, in accordance with applicable law.