Medical Credentialing Specialist

Description

Job Title: Medical Credentialing Specialist

Department: Compliance

Reports to: Compliance Officer

Summary:

The Credentialing and Records Coordinator is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing packages as required by the organization, commercial payers, Medicare and Medicaid. This position will also be responsible for gathering, processing and maintaining patient records and reporting patient information for health standards.

Essential Duties And Responsibilities:  

1. Processing provider applications and facility to all health plans. Abstracting pertinent data and completing payor specific enrollment documents to assure claims acceptance. Processing and tracking of applications to ensure timely enrollment, and        providing the revenue cycle department with provider ID numbers for claims processing.
2. Maintaining the provider enrollment database. Updating the database with new providers, and with changes in provider information. Suggesting updates to the application to improve efficiency.
3. Enter and maintain provider applications, contracts, and updates into the practice/provider Credentialing files.
4. Complete Medicare enrollments via internet PECOS and work with local MACs for provider enrollment issues
5. Complete variety of state Medicaid enrollments
6. Verify prospective and current providers’ license, liability insurance, CDS certificate, and DEA certificate, providers’ education, hospital privileges, board certification, malpractice coverage and other criteria as required.
7. Track payer contract applications status and provider participation levels, including recredentialing/revalidation requests.
8. Meet required turnaround times and accuracy rates.
9. Facilitate provider-related research based on suspended claims, address returns, and other feedback opportunities.
10. Gathers patient information by collecting demographic information from a variety of sources; interacting with registration areas and physicians' offices; retrieving information from automated printer.
11. Process attorney release of records within 72 hours of patient being seen.
12. Maintains master patient index by completing assigned portion of daily audit trail; corrects and communicates problems according to established procedures.
13. Maintain a daily audit trail of release of medical records; corrects and communicates problems according to established procedures.
14. Initiates the medical record by creating and processing the patient care record folder.
15. The coordinator will process charts through Medical Records Drive; documenting reasons charts cannot be retrieved for statistical and follow-up purposes.
16. Keeps health law firms informed by communicating availability or unavailability of the record.
17. Perform other duties as assigned in CBO within skillset.

Qualifications:  

1. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 
2. The requirements listed below are representative of the knowledge, skill, and/or ability required. 
3. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/Or Experience:

Associate's   degree (A. A.) or equivalent from two-year college or technical school; or   six months to one year related experience and/or training; or equivalent   combination of education and experience.