Payor Credentialing Specialist (remote)

Remote position requiring payor credentialing and payor enrollment experience.

About the role

Leads, coordinates, monitors, and maintains the payor and provider credentialing and re-credentialing processes. Facilitates all aspects of payor credentialing including payor enrollments, revalidations, maintenance, license updates, and follow-up on payor credentialing-related A/R issues. Ensures interpretation and compliance with appropriate accrediting and regulatory agencies while developing and maintaining a working knowledge of statutes and laws relating to payor credentialing and enrollment. Responsible for the accuracy and integrity of the credentialing database system and related applications. Works under the supervision of the Director of Payor Credentialing in conjunction with the Chief Revenue Officer.

Responsibilities

• Prompt and regular attendance at an assigned work location.
• Complete or oversee the completion of assigned tasks/projects in a timely manner.
• Enroll and credential facilities as well as providers with insurances; ensure all payor criteria are met.
• Lead, coordinate, and monitor the collection, review, and analysis of payor enrollment applications.
• Ensure accuracy and completeness of payor enrollment submissions including supporting documentation.
• Follow up with providers and insurances for timely credentialing and enrollment process(es).
• Monitor application progress and follow up with payors as needed until confirmation of credentialing and network load is complete.
• Identify issues that require additional investigation and evaluation, validate discrepancies, and ensure appropriate follow-up.
• Review and update, if necessary, health plan directories, agencies, and other appropriate entities for current and accurate provider information.
• Respond to inquiries from other healthcare organizations, interfacing with internal and external customers on day-to-day credentialing and enrollment issues.
• Utilize the credentialing database, optimizing efficiency, and perform query, report, and document generation.
• Enter and maintain accuracy of data input into Credential Stream, PECOS, NPPES, CAQH, Optum, Availity, and other payor portals.
• Verify provider accuracy in payor directories.
• Provide support with managed care delegated credentialing audits; conduct internal file audits.
• Ensure compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state laws) and policies and procedures in all aspects of the payor credentialing process.
• Participate in community and public relations activities as assigned.
• Attend and complete all required trainings as assigned.

Requirements

• At least 3 to 5 years of experience in payor credentialing/enrollment.
• Bachelor’s degree preferred or comparable work experience.
• Current CPCS or CPMSM certification or working towards certifications.
• Experience or working knowledge of full credentialing cycles: initial payor credentialing/enrollment, maintenance, and revalidation.
• Experience or working knowledge of CredentialStream credentialing platform or other credentialing database software.
• Excellent attention to detail, problem-solving, critical thinking, and analytical skills.
• Strong working knowledge of word processing, spreadsheets, data entry, database experience, and other computer-related skills.

Skills

• Basic understanding of substance use disorder.
• Highest ethical and professional standards.
• Strict confidentiality.
• Excellent written and verbal communication skills.
• Proficient in Adobe, Excel, PowerPoint, Word, Outlook, and other Microsoft Office applications.
• Well-organized, capable of juggling multiple projects, and accustomed to tight deadlines.
• Ability to work effectively and independently with both clinical and non-clinical colleagues.
• Ability to perform research independently.

Physical Requirements

• Speaking and hearing ability sufficient to communicate effectively by phone or in person at normal volumes.
• Vision adequate to read correspondence, computer screen, forms, etc.
• Ability to sit for long periods of time, some bending, stooping, and stretching.
• Variable workload, periodic high activity level.
• Keyboarding for long periods of time.