SCOPE / GENERAL PURPOSE OF JOB:

 Responsible for the completion of timely credentialing and re-credentialing applications with applicable payers, ancillary, facility and independent practitioners. Accountable for seeking resolution to problems with payers as they relate to credentialing, ensuring excellent communication with CBO management and clients, thereby assuring client satisfaction. Responsible for ensuring timely credentialing to allow revenue generation and obtaining accurate provider numbers as it relates to claim submission requirements to facilitate billing. 

 ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Demonstrates thorough understanding and knowledge of Government and Commercial payer and provider credentialing, re-credentialing, hospital appointment and re-appointment processes/requirements, to include ancillary credentialing, re-credentialing
• Prepares, reviews and submits credentialing, re-credentialing, appointment, re-appointment applications.
• Preforms correct and timely application follow-up per Dept. Policy and Procedure to ensure continued client payer and/or hospital participation.
• Loads and maintains each credentialing client’s data within the Wybtrak database and quarterly in CAQH.
• Contacts medical office staff, licensing agencies, and insurance carriers to complete credentialing and re-credentialing and/or hospital, ancillary applications timely.
• Generates on a monthly basis, Wybtrak expirable reports and contacts any applicable client for renewed non-expired credentialing document(s).
• Updates and maintains all client Insurance PAR LIST(s) with most current credentialing status. Updates Dept. Contracting Staff and management regarding credentialing status per client, as applicable
• Maintains extensive working knowledge of the provider credentialing, re-credentialing, appointment processes.
• Expands knowledge base by participating in educational opportunities.
• Ensures strong communication with CBO management team.
• Ensures compliance with Company Policies and Procedures to maximize efficiency. Ensures compliance with appropriate industry regulations and State and Federal regulations.
• Maintains working knowledge of applicable laws and regulations as they relate to assigned responsibilities.
• Maintains confidentially of all information related to patients, clients, finances and cost effective health care delivery issues.
• Demonstrates the ability to work well with peers while ensuring a strong cohesive team.
• Additional duties as assigned.

 EDUCATION AND/OR EXPERIENCE: 

• 2 years of experience in physician credentialing, re-credentialing.
• Healthcare business office processes and professional revenue cycle management experience a plus.

QUALIFICATIONS:

• Knowledge of organization policies and procedures.
• Knowledge of health care administration principals.
• Knowledge of basic business office billing policies and procedures.
• Knowledge of credentialing, re-credentialing and hospital appointment, re-appointment operating procedures and practices.
• Skill in exercising initiative, judgment, discretion, decision-making and organizational skills to achieve business unit objectives.
• Skill in identifying and resolving problems.
• Ability to communicate effectively and professionally.
• Ability to establish and maintain effective professional working relationships with all employees, clients and outside entities
• Ability to communicate effectively orally and in writing.
• This position relies on experience and judgment to plan and accomplish goals.