Under supervision of the Director, the Payor Enrollment Specialist is responsible for all aspects of the credentialing process. Including, but not limited to maintaining current information for each provider via the credentialing databases and online systems. Maintain and manage a credentialing work flow to ensure accurate and timely renewal of licenses and other certifications. Produce monthly productivity reports as well as ad hock reports as needed. Ability to adjust to a constantly changing environment. This department services the One Brooklyn Health System and all affiliated physician enrollment services across three campuses.

• Responsible for enrolling physicians, allied health professionals and other practitioners in all commercial and governmental health plans where OBH physicians are contracted.
• Maintains compliance with regulatory and accrediting bodies.
• Participates in the ongoing development and implementation of credentialing processes and procedures.
• Provide process improvement input on the daily workflows and processes.
• Completes provider managed care credentialing and re-credentialing applications; including Medicare and Medicaid re-validations.
• Assists with annual payer delegation audits.
• Participate in the development of and adherence to:
  • Departmental rules and regulations and Governance bylaws.
  • Policies pertaining to medical staff, practitioner/provider and the organization.
• Collect and maintain copies of confidential credentials i.e. current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
• Inputs data and maintains data integrity for our payor enrollment database(s).
• Maintains assigned CAQH provider profiles.
• Monitors license and certification expirations for all providers to ensure timely renewals.
• Maintains and updates department credentialing spreadsheets biweekly. Provides relevant credentialing information to management and billing department.
• Analyzes and updates verification information as needed.
• Coordinates monthly conference calls with payors as part of the departments quality management program.
• Responsible for generating and monitoring credentialing reports via Cactus.
• Assists in denial resolution and root cause analyses specific to payor alignment and payor enrollment issues.
• Responds to Physician and employee inquiries.
• All other duties as assigned.

Education:

• Bachelors degree preferred.

Experience:

• Minimum three (3) years of related managed care/credentialing experience in a hospital setting preferred.

Knowledge and Skills:

• Must have complete knowledge of the credentialing processes as it relates to Managed Care, Medicare, and Medicaid.
• Ability to manage multiple projects with proven experience prioritizing multiple assignments.
• Ability to communicate with all levels of management and physicians.
• Excellent attention to detail.
• Ability to research, analyze and collate data.
• Ability to work independently with minimal supervision.
• Ability to establish and maintain effective working relationships with providers, patients, management, staff and contracted payers.
• Proficient use of Visual Cactus and Microsoft Office applications (Word, Excel, Access).
• Understanding of the delegated process workflow and requirement under NCQA.
• Ability to effectively navigate CAQH, PECOS and EMEDNY.
• Knowledge of NCQA credentialing standards and JCAHO standards preferred.

Licenses, Certifications:

• Certified Provider Credentialing Specialist (CPCS), preferred.
• Or Certified Professional Medical Services Management (CPMSM), preferred.

Physical Requirements:

• Position required prolonged periods of sitting and use of a computer and screen viewing throughout the workday.
• Position will be required to stoop, bend, lift, and carry items weighing up to 25 pounds.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the One Brooklyn Health System.

OBHS is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.