Credentialing and Managed Care Specialist - 10 hrs/wk, 1st shift

PURPOSE OF THIS POSITION

The purpose of this position is to perform credentialing and enrollment activities with governmental payers, commercial and managed care payers and networks for BVHS facilities, entities and employed or contracted physicians. Coordinates communication with internal and external parties on credentialing 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. Coordinates submission of service line applications for payer "centers of excellence" or other certification programs. Maintains credentialing and enrollment databases for each provider and for use by patient revenue cycle for billing. Performs administrative support functions for managed care patient centered medical home, including management of network participation files, medical home enrollment files, provider files and preparation of payment reports. Performs 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 and acts as liaison with payers for resolution of contract related claims payment issues.

JOB DUTIES/RESPONSIBILITIES

Duty 1: Leads operational projects and performs routine and special analyses and data collection projects for the Managed Care department to advance successful implementation of the managed care strategy.

Duty 2: Conduct contract negotiations with specified payers. Leads contract implementation and renewal activities for all payers for BVHS entities and physicians

Duty 3: Creates, maintains and distributes timely, accurate and detailed databases for contract management (participation status, rates, contacts, renewals, contracting process tracking, etc.), NPIs, W-9, tax IDs, provider numbers, etc. to ensure BVHS constituents have information needed to perform their jobs as relates to billing and managed care.

Duty 4: Manages and performs data management, reporting and analytic projects for various projects.

Duty 5: Coordinates activities related to employer, provider and payers, including workshops, seminars, educational sessions, health promotion, etc. to promote BVHS services and ensure access to payer volume as well as to facilitate compliance with managed care contracts.

Duty 6: Maintains current knowledge base regarding governmental and commercial payer enrollment and credentialing requirements. Collects, completes and coordinates submission of timely and accurate provider enrollment and certification applications and credentialing and recredentialing information to commercial and governmental payers for BVHS entities and physicians to ensure contracted status

Duty 7: Researches and intervenes to resolve systemic billing/payment issues with contracted payers related to provider enrollment and credentialing, payer system setup issues, etc. working in cooperation with patient Revenue Cycle.

Duty 8: Provides administrative support activities as needed to the managed care dept.

REQUIRED QUALIFICATIONS

• Bachelors degree in business or health-related field, or equivalent relevant experience.

• 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.

• Demonstrated skills in using Excel, Word and Microsoft Access.

PREFERRED QUALIFICATIONS

• Three years experience in managed care, insurance, physician credentialing or billing.

• Relevant experience with governmental provider enrollment and certification processes.

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to sit for four hours and walk three hours per day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. Individual must have excellent verbal communication skills to perform daily tasks. This associate must be able to operate a motor vehicle.