Medicare Enrollment and Credentialing Analysts

Overview

Summary:

The Payer Relationship Revenue Cycle Analyst is responsible for the Reliant Senior Living payer relationship functions including government payer enrollment and administration, payer credentialing, 3 rd party insurance payer contract management, and payer maintenance. The Payer Relationship Revenue Cycle Analyst monitors performance, performs analytics, provides education, and may be responsible for the oversight of one or more outsourced teams responsible for aspects of the payer relationship functions. In this role, the Payer Relationship Revenue Cycle Analyst will represent Reliant Rehabilitation’s commitment to quality & service in all interactions with the communities, clients and clinic teams.

Responsibilities

Essential Duties and Responsibilities:

• Manage all aspects of Reliant Senior Living’s enrollment and maintenance of government payers. This includes but is not limited to: NPI application and maintenance, PECOS enrollment, revalidation and change of ownership processing. Railroad, DME and other special program enrollment and management.
• Coordinate and manage all Medicare and 3 rd party payer provider and group practice reporting to ensure compliance with state, federal and contractual reporting requirements.
• Manage all payer configuration in the Reliant Senior Living EHR related to credentialing holds.
• Assist with research and identification of Medicare Advantage plans that Reliant Senior Living should contract with.
• Initiate contracting/credentialing introducing Reliant Senior Living to payers and following payer protocols to be contracted at the highest level available from each Managed Care payer.
• Review proposed contract fee schedules or other payment structures to determine overall impact to Reliant Senior Living financial and operating goals.
• Coordinate review and approval/decline with appropriate Reliant corporate team members.
• Manage all signed 3rd party contracts ensuring that contracts are reviewed and renewed on time and in the best interest of Reliant Senior Living.
• Manage Council for Affordable Quality Healthcare ProView (CAQH) profiles on behalf of Reliant Senior Living providers and locations.
• Montor and report on contract performance and work with other RCM team members to ensure constant process improvement.
• Ensure all existing and new providers are credentialed with contracted payers in a timely manner and that any financial losses due to credentialing denials is mitigated.
• Participate in regular payer and payment trend report meeting for the Reliant Senior Living Contract Approval Committee and other attendees as requested by leadership.
• Monitors, interprets and summarizes information in payer provider manuals, newsletters, bulletins and other payer methods of communication and provides this information to the appropriate teams within Reliant Senior Living in support of optimal revenue cycle function.
• Create tools, dashboards and education for clinic team members to ensure that non-credentialed providers are not scheduled until fully credentialed.
• Monitor accuracy, develop rubrics, create score cards and utilize other tools and methods to identify areas of opportunities and work with the appropriate corporate, clinic or partner resources to ensure constant process improvement.
• Develop training and tools, and provide education to clinic team members as necessary to ensure effective utilization of all payer relationship tools and thorough understanding of related processes and data.
• Represent payer relationship within the Revenue Cycle team.
• Attend all mandatory meetings, training, and assignments as delegated.
• Perform other duties and responsibilities as assigned.
• Must adhere to the polices, principles, and guidance within the Employee Handbook and Code of Business Conduct.
  
  

Qualifications

Competency:

• Proficient in Microsoft Office tools with a strong emphasis on Excel and Power Point.
• Strong interpersonal, oral, written communication skills to include the ability to mentor clinical team members in the business aspects of Revenue Cycle.
• Demonstrated ability to organize, prioritize and manage multiple tasks in a growing company.
• Strong knowledge of outpatient healthcare billing systems and processes.
• Ability to build strong relationships with a diverse population.
• Ability to read, write, speak, and comprehend in English: instructions, correspondence, memos, and reports.
• Ability to work in a fast-paced, productive work environment.
• Ability to make independent decisions and problem solve as appropriate.
• Ability to effectively manage and motivate the team.
  
  

Education/Experience

• At least 5 years of business-office revenue cycle experience in an outpatient setting.
• 3 years of experience with at least 2 of the following payer relationship roles/systems: CAQH, PECOS, NPPES, Availity Payer Spaces, Availity Enrollment Center, Waystar, Trizetto, Instamed or Experian EDI enrollment.
• Previous experience in group practice with multiple offices and a national footprint.
• Previous experience in initiating contract requests, managing provider rosters, reviewing contract terms and managing government and 3 rd party portal access in an outpatient setting.
• Strong working knowledge of outpatient electronic health record systems (EHR); experience with Prompt Health a plus.
• Strong experience using reporting tools such as Power BI and Excel.
• Thorough knowledge of Medicare and third-party billing in an outpatient setting.
  
  

Work 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 essentials functions. The noise level in the work environment is usually moderate.