Specialist- Credentialing Payor

Provider Number & Payor Enrollment Management:
• Acquires provider numbers from major carriers for medical staff in large clinic system by application process (paper and online) for new hires.
• Acquires numbers to link existing providers to additional locations of practice within clinic system.
• Terminates provider numbers due to termination of employment with the clinic system.
• Maintains an extensive tracking system for pending provider numbers for a large physician data base.
• Completes applications for major carriers for all new medical providers and resolves issues or documentation requirements relating to network in-process enrollment by personal response.
Credentialing/Re-credentialing:
• Completes re-credentialing applications for existing providers for all insurance carriers on a pre-determined time schedule and subsequent follow up to ensure continuity of approval by Credentialing Committee.
• Implements the Health Link credentialing/re-credentialing policies and procedures which comply with the NCQA guidelines for all Health Link provider applicants
• Monitors provider credentialing resource, identifies potential problems and brings them to the attention of the Health Link Manager and Health Link Credentials Chairman.
• Remains current in all aspects of the NCQA credentialing policies and procedures.
Audits:
• Conducts bi-annual audits of the credentialing files and policies and procedures of those managed care organizations to which Health Link delegates credentialing responsibility.
• Coordinates annual audit requests in regard to delegated credentialing agreements.
• Maintains Provider Application status spreadsheet for accountability and tracking accessed by other credentialing department staff and Manager
• Maintains the provider credentialing database
• Conducts queries while providing routine monthly, quarterly and annual reports and special reports as requested.
Filing System:
• Maintains extensive provider files for ready reference to medical credentials, application copies, and miscellaneous correspondence.
• Verifies all provider application information through NCQA approved sources within NCQA specified timeframes.
• Provides accurate information to the Health Link Manager and Credentials Committee within NCQA required timeframes