Provider Coordinator (52303)

About Us

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company—we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative, and who have a passion for continuous learning.

About the Role

The primary goal of the Provider Coordinator is to ensure quality assurance of provider data integrity, respond to provider inquiries with research and resolution, and ensure proper categorization of the provider directory. This role supports credentialing and provider relations activities while ensuring the accuracy, timeliness, and compliance of the provider directory. This role partners cross-functionally to maintain data integrity and meet CMS regulatory requirements for provider data accuracy and accessibility.

Responsibilities

• Verify Provider Data integrity with ongoing monitoring and respond to daily inquiries in a timely manner.
• Assist in maintaining accurate Provider/Vendor records and Provider Directory.
• Educate and assist providers to maximize data integrity and provider experience.
• Actively participate and assist in meeting CMS guidelines.
• Respond, research, and resolve Provider Inquiries within JIRA and other sources.
• Serve as a point of contact for provider data updates and corrections.
• Coordinate initial and recredentialing processes for providers in accordance with OK and CMS standards.
• Track credentialing timeliness and ensure compliance with turnaround requirements.
• Process applications and credentialing paperwork, checking for completeness and accuracy.
• Obtain primary source verification of competencies relating to the applicant such as relevant board certifications, health facilities affiliations, licensure, certifications, DEA, OBNDD certificates, and malpractice coverage following GlobalHealth Credentialing Policy and Procedures including CMS requirements.
• Query and process primary source verification, verification, and accreditation information including NPDB, OIG, SAM, and Medicare Opt Out.
• Communicate via email, fax, or mail with providers.
• May prepare credentialing files and submit practitioner and provider information to Credentialing Committee for approval in a timely manner.
• May support review of credentialing files and databases for both practitioners and providers.
• Maintain communication with appropriate practitioners to ensure records are up-to-date and consistent.
• Notify practitioners and providers of Credentialing Committee decisions and renewal dates and respond to requests for status of credentialing.
• Manage, request, and follow up on expirables as needed (license, COI, Board Certifications, etc.).
• Collaborate on outreach to providers for data validations.
• Coordinate with delegated vendors to validate provider data accuracy and timelines.
• Support oversight of delegated entity credentialing rosters and other notifications related to directory accuracy and credentialing timelines.
• Maintain confidentiality of all credential files.
• Complete various work assignments as requested by supervisor in a timely manner.
• Maintain current desk procedures and reference materials.
• Maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Perform other duties as assigned.

Requirements

• High School diploma or equivalent required.
• Three to five years of credentialing experience.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
• Knowledge of CMS, NCQA, and state regulatory requirements related to provider credentialing and directory accuracy.

Skills

• Computer Proficiency: Demonstrated proficiency in the use of personal computer applications; specific skills to include Microsoft Word, Outlook, Excel v-lookup, and ability to build and compare files.
• Interpersonal Skills: Ability to quickly develop rapport and work effectively and professionally with all levels of personnel.
• Critical Thinking Skills: Ability to investigate/research problems and issues and to recommend associated corrective actions.
• Discretion: Ability to manage sensitive or confidential information in a professional and discreet manner.
• Exercises judgment when dealing with applicants by demonstrating the ability to analyze situations and use tact and diplomacy to arrive at resolutions.
• Proper organizational/time management skills.
• Preferred experience with Medicare Advantage plans.
• Working knowledge of credentialing processes and guidelines, primary source verification, and knowledge of types of modalities, specialties, and education required for each practitioner and provider.
• Strong verbal, written, and organizational skills; must be self-directed/initiative-taking and must have analytical, problem-solving, and decision-making abilities.
• Must have the following mental abilities: alertness, precision, analytic ability, problem-solving, memory, communication, creativity, concentration, judgment, imagination, initiative, resilience to push through barriers to the solution.

Work Environment

Current work environment is remote, however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure, or damage and will adhere to all GlobalHealth privacy and security policies.

No travel required. This position is not a supervisory position.