Provider Enrollment Specialist

Credentialing Specialist

This position functions in a complex payer credentialing environment with changing health care rules, regulations and laws under the leadership of the Director of Professional Services. Responsible for the timely, efficient and accurate economic credentialing and provider enrollment of eligible West Virginia United Health System, WVU Health Sciences Eastern Division and WVU Health Sciences Charleston Division medical billing providers and facilities with contracted managed care and governmental plans. This position has continuous contact with internal and external customers including physicians, other healthcare providers, administrators, support staff and payor representatives. Additionally, this position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered. Ensures compliance with regulatory agencies and maintains a working knowledge of statues and laws that affect the credentialing/enrollment process. This position works collaboratively and gives support to the credentialing process.

Minimum Qualifications:

Education, Certification, and/or Licensure:

1. High School Diploma or equivalent.

Experience:

1. Two (2) years of health care industry experience

Preferred Qualifications:

Experience:

1. Health care industry experience in professional billing, physician's office or credentialing preferred.

Core Duties and Responsibilities:

1. In collaboration with hiring/onboarding personnel will serve as a concierge to guide the providers through the economic credentialing/enrollment and recredentialing/revalidation process. (managed care/Medicare/Medicaid/NPPES/I&A).

2. Based on information from provider enrollment vendor, develops, maintains and monitors credentialing/enrollment database with applicable effective dates, to ensure an active status among contracted managed care payers, Medicare, Medicaid and other governmental plans.

3. Ensures licenses and certifications are accurate and active among all markets.

4. Tracks and monitors the return of registration packets and alerts hiring managers and/or recruiters of issues.

5. Develops, manages, and utilizes a standard set of reports to track the registration process and communicate the status and successful enrollment to appropriate Vice Presidents, Administrators, Directors and Managers and billing units in an effort to manage the start date and prevent loss of revenue when possible.

6. Regularly coordinates with IHS Vice Presidents, Administrators, Directors and Managers to obtain information for new facilities, practice locations, providers and services to be added under existing contracts for smooth revenue collection and contract compliance. This may require queries to the payers for strategic planning in advance of new services.

7. Acts as an educational resource related to enrollment of facilities, practice locations and various provider types and is available for consultation to internal and external clients.

8. Analyzes problems and draws accurate conclusions in regards to provider enrollment and credentialing issues. Proactively identifies and troubleshoots issues affecting provider payment. Then, resolves, provides recommended solutions, or forwards more complex issues onto appropriate person(s) for handling.

9. Works collaboratively with Director of Professional Services, Manager, Professional Services, and Supervisor of Managed Care in regards to day-to-day operations and special projects.

10. Maintains a high level of confidentiality in all aspects of the position.

11. Must have a basic understanding of messenger model network and managed care contracting as related to the credentialing process.

12. Must have a basic knowledge of credentialing policies, regulatory requirements and accreditation standards.

Physical Requirements:

The physical demands described here are representative of those 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.

Working Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

Skills and Abilities:

1. Strong analytical, problem-solving, time management, planning and organizational skills with excellent attention to detail and accuracy.

2. Ability to function independently with minimal supervision, in a demanding and fast paced environment.

3. Intermediate skill level in Microsoft Word, Excel, Access, Outlook.

4. Ability to establish and maintain effective working relationships with providers, staff, and other agencies; provide a positive service attitude when dealing with internal and external customers.

Additional Job Description:

Scheduled Weekly Hours: 40

Shift: Non-Exempt

Company: SYSTEM West Virginia University Health System

Cost Center: 649 SYSTEM Managed Care and Payer Relations

Address: 1370 Johnson AveBridgeportWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.