Credentialing & Provider Enrollment Lead (Temporary) 36 hrs/wk.
Blanchard Valley Regional Health Center

Findlay, Ohio

Posted in Medical and Nursing


This job has expired.

Job Info


PURPOSE OF THIS POSITION

The purpose of this position is to oversee and lead the functions and activities of provider credentialing and enrollment activities with governmental payers, commercial and managed care payers and networks for BVHS facilities, entities and employed or contracted physicians, including maintaining current knowledge on requirements. Leads the team responsible for performing credentialing and provider enrollment, including assigning work requirements, duties and work timelines. Leads communication with internal and external parties on credentialing and provider enrollment process, to support the timely, accurate and complete credentialing, re-credentialing and enrollment of all BVHS facilities, entities and employed/contracted physicians and midlevel providers in governmental and payer plans and networks, as well as to address inter and intra-organizational issues that affect the processes. Participates as subject matter expert on project planning teams. Oversees the structure and use of the credentialing and enrollment database(s). Oversees and performs customer service for managed care division.

JOB DUTIES/RESPONSIBILITIES

Duty 1: Leads, organizes and oversees the processes and functions of credentialing and provider enrollment to optimize efficiency and timeliness. Assigns workload and priorities to credentialing specialist support staff.

Duty 2: Oversees the structure of and sets parameters for use of credentialing and enrollment database(s) for professional providers and entities and makes available as appropriate for use by patient revenue cycle.

Duty 3: Maintains current knowledge on CMS and other government entities' provider enrollment requirements and payer credentialing requirements. Acts as a subject matter expert for internal projects and issues. Proactively monitors upcoming changes in or expansion of credentialing and enrollment rules and regulations; takes necessary steps to alert appropriate parties within BVHS to changes; and leads activities to maintain BVHS compliance with changes.

Duty 4: Leads communication with internal and external parties on credentialing and provider enrollment process, to support the timely, accurate and complete credentialing, re-credentialing and enrollment of all BVHS facilities, entities and employed/contracted physicians and midlevel providers in governmental and payer plans and networks, as well as to address inter and intra-organizational issues that affect the processes. Communicates directly with payers for resolution of credentialing and contract related claims payment issues.

Duty 5: Collects, completes and submits timely, accurate and complete provider enrollment and credentialing applications and information to commercial and governmental payers and networks for BVHS facilities, entities, service lines, physicians and midlevel providers to ensure enrollment and/or participation is approved by and loaded in payer plans or networks.

Duty 6: Creates, maintains and distributes timely, accurate and detailed databases for payer credentialing management (providers, participation status, submission dates, contracting process and status tracking, etc.), NPIs, W-9, tax IDs, provider numbers, etc. to ensure BVHS internal constituents have information needed to perform their jobs as relates to billing and managed care.

Duty 7: Works closely with Patient Revenue Cycle department to resolve global or systemic billing/payment issues related to provider enrollment and credentialing, payor system setup issues, etc.; acts as liaison between payer and Patient Revenue Cycle as needed to resolve issues.

Duty 8: Sets standards for and performs or delegates customer service for managed care division, responding to internal, patient and external requests for network participation information, resolution of network participation related claims payment issues. Reviews payer notices and communications and disseminates information within BVHS to appropriate departments to promote compliance with payer requirements.

Duty 9: Coordinates the collection, aggregation, internal approvals and submission of initial and renewal applications for service line or departmental certifications by payers as "certified", approved, or "center of excellence" programs.

Duty 10: Provides ongoing and project-based data management support as needed to the managed care, medical home and NWOHP areas.

REQUIRED QUALIFICATIONS

  • Bachelor's degree in business or health-related field, or equivalent relevant experience.
  • Three years' experience in managed care, insurance, physician credentialing or billing.
  • Relevant experience with governmental provider enrollment and certification processes.
  • A valid driver's license is required (if you do not have a valid Ohio driver's license you must obtain one within 30 days of your residency in the state). You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
  • Excellent organization, time and work process management skills.
  • Strong database management and analytical skills.
  • Strong problem-solving skills and operation improvement orientation.
  • Positive service-oriented interpersonal and communication skills required.
  • Demonstrated skills in using Excel, Word and Microsoft Access.

PHYSICAL DEMANDS

This position requires a full range of body motions with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit for four to six hours a day and stand for one hour a day. The individual must e able to lift twenty to fifty pounds and reach above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business and community involvement.

*BVHS

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