Credentialing & Enrollment Representative

Position Overview:

Under the direction of the Provider & Enrollment and Contracts Manger, the Credentialing & Enrollment Representative evaluates, analyzes, and coordinates all aspects of the credentialing and recredentialing processes of clinical providers (Medical, Dental, Optometry and Behavior Health) and clinics with participating health insurance plans.

Credentialing & Provider Enrollment:

• Enroll with health plans using accurate and detail orientation to be able to complete health plan enrollment applications and submit enrollment to payors in a timely manner
• Deep understanding of health plans including CAQH, Medicare, Medicaid, Managed Care and Commercial Plans
• Determine re-credentialing dates and complete re-credentialing of all providers and clinics(groups) with appropriate health plans
• Maintain all enrollment data and follow ups with health plans in centralized spreadsheets for each client 
• Possess knowledge and ensure CAQH are created, updated on a quarterly basis
• Enters, updates and maintains data from provider applications into credentialing database, focusing on accuracy and interpreting or adapting data to conform to defined data field uses, and in accordance with internal policies and procedures
• Ensure all provider demographic information as well as NPPES is kept up to date at all times
• Participate in agenda prep meetings as well as client calls at all times
• Electronically prepare and track, and follow-up on appropriate verifications for efficient, high-volume processing of individual provider applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines

Reporting & Analytics: 

• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies
• Identifies, analyzes and resolves extraordinary information or discrepancies that could adversely impact ability to credential and enroll practitioners
• Be prepared to provide feedback and give updates pertaining to credentialing and health plan enrollment for providers and clinics

Collaboration & Communication:

• Communicates clearly with providers, their liaisons, medical staff leadership and Administration, as needed to provide timely responses
• Communicate regularly with your colleagues, management, health plans and providers at all times
• Be available for all internal and client meetings in a timely manner
• Be able to take initiative and take a proactive response to all identified issues as opposed to being reactive after something goes wrong 
• Be able to problem solve and come up with solutions to credentialing problems and report to management when necessary 
• Be able to think outside the box and identify issues and problems before they happen

Continuous Improvement: 

• Maintain current and accurate records of provider and credentialing provider data, including initial and re-credentialing

• Educational Background: Bachelor’s degree in Healthcare Administration, Business, Finance or a related field (preferred)

   

• Experience: A minimum of 2 years of full-time experience in all facers of credentialing, including interactions with healthcare providers. Experienced with Medicare, Medi-Cal, Managed Care and Commercial insurances. Proficient in enrollment terminology

• Expert Industry Knowledge: Strong knowledge of Federally qualified health centers (FQHCS) and Community Health Centers (CHCs)

• Communication & Collaboration: Strong ability to collaborate with cross-functional teams

• Detail-Oriented: High level of accuracy, with the ability to set and maintain priorities in a fast-paced environment

• Technical skills:  Strong knowledge in the use of Microsoft Excel, Word, and Outlook

• Adaptability and flexibility: Should be able to adapt to changes in regulations, technologies, and industry trends and adjust accordingly