Responsible for all aspects of the credentialing, recredentialing and privileging processes for all medical providers who provide patient care at all Memorial Care. Responsible for ensuring providers are credentialed, appointed, and privileged with health plan and maintaining compliance with credentialing delegation oversight for providers whom delegation has been granted. Engage in quality control activities within Provider Relations/Provider Governance and Risk Department and delegated entities in support of internal and delegated payor audits. Ensure compliance with payor policies, State, Federal, and NCQA requirements associated with delegated credentialing. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications. Embodies the Memorial Health System Mission and Vision.
**This is a 100% remote role**
- Maintain provider enrollment files of all providers actively submitting charges under all affiliates. Approximately 200 open files at a given time.
- Organizes new provider data received from various sources in order to prepare and distribute new provider informational packets used for credentialing paperwork.
- Complete all necessary credentialing or enrollment of new providers for all contracted plans (20+)
- Complete on-line applications for Medicare, Medicaid and State of Illinois and print same to distribute to provider for signature.
- Complete the Council for Affordable Quality Healthcare (CAQH) National application on-line and notify plans via email. Email to include all necessary attachments.
- Create, maintain and distribute a provider credentialing/participation status listing including effective dates.
- Review, update as necessary and authorize CAQH provider data every four months.
- Upon receipt of re-credentialing request review CAQH and State of Illinois applications. Obtain all signatures needed on re-credentialing application.
- Follow up with all payers regarding status of credentialing applications. Maintain credentialing contact list for each payer.
- Review and correct claims stopped in claim scrubber for credentialing edits.
- Coordinate with MMC Medical Staff Office to provide necessary information to assist with hospital privilege reappointment requests.
- Answer all questions regarding credentialing status from PBS management or staff, clinic management or staff and providers.
- Function as a resource for clinics on daily operational issues including identification and selection of correct insurance plan for a patient, W-9 requests, Cerner to billing system registration issues, missing tickets, etc. Provide training to new clinic staff upon request.
- Maintain complete provider rosters by clinic and/or organization and provide as requested.
- Participate in professional activities to enhance personal growth and development through educational programs, workshops, and seminars to keep current in the field.
- Promote good customer service and open communications by setting an example and treating everyone fairly and with courtesy and respect.
- Perform other duties as assigned by management.
- High school diploma or equivalency is required. Associates or Bachelor's degree in Healthcare, Business Administration, Accounting or Management, and/or equivalent years of experience preferred.
- Minimum of three (3) years of Patient Accounting or Medical Business Office experience required. Experience should cover all aspects of physician billing procedures, knowledge of regulatory requirements, and an understanding of third party agreements.
- Minimum of two (2) years of experience in completion of credentialing paperwork in a health care provider office.
- Must possess valid Illinois driver’s license and must be deemed as an acceptable driver in accordance with the MHS Fleet Safety Policy (five year MVR will be required).
- Ability to relate to people of diverse backgrounds, training, and experience.
- Required to schedule, meet and maintain daily and monthly routines and efforts as necessary to coordinate these routines. Must be able to exercise initiative, judgment and decision-making in meeting Client and Department objectives.
- Must have sufficient oral and written communication skills to interact with Physicians and other providers, their office managers and staff, Insurance carriers and all levels of staff.
- Must have working skills and familiarity with computer applications. Knowledge of physician billing software and personal computer applications like Microsoft Word, Microsoft Excel, and Microsoft Office Outlook is required.
- Knowledge of CPT-4 and ICD-9-CM diagnostic coding preferred; fluency in reimbursement impact in relation to assigned CPT-4 or ICD-9-CM coding is highly desirable.