Payer Credentialing Representative

Description

Job Summary

Under the direction of the Supervisor of Payer Credentialing, coordinates the process for Health System and employed physician delegated credentialing for managed care payers, as well as non-delegated credentialing for applicable managed care payers. Manages master physician matrix and delegated credentialing matrix on a monthly basis. Manages projects and facilitates resolution to issues related to credentialing and contract performance. Serves as a liaison resolving issues between the Health System, employed physician group practices, hospital/physician billing, and health plans.

Job Specific Duties

• Supports the payer delegated and non-delegated credentialing process for the hospital and employed physician group. 
• Follows appropriate processes to monitor and maintain systematic, timely credentialing and re-credentialing requirements. 
• Serves as the primary liaison, supporting the Supervisor of Payer Credentialing, for delegated credentialing process and acts as a resource to external and internal customers regarding credentialing and health plan inquiries. 
• Collaborates with Medical Staff on the credentialing audits in compliance with the managed care delegated credentialing agreements. 
• Establishes and maintains professional working relationships with payer counterparts. 
• Serves as point of contact for health plans/payers regarding delegated credentialing files, troubleshooting discrepancies, & aligning data to achieve successful payment of employed physician claims. 
• Serves as point of contact for NCPS and in collaboration with the Supervisor of Payer Credentialing,  follows up with payers on credentialing issues that require additional investigation and evaluation. 
• In collaboration with the Supervisor of Payer Credentialing, responsible for timely submission of Medicaid applications (new and/or renewals), NPEES reviews, CAQH Attestations, and monthly delegated credentialing updates .
• In collaboration with Managed Care Specialists, coordinates, prepares, & disseminates JOC agendas with internal/external constituents timely & accurately with much attention to detail. 
• Actively participates in and learns managed care initiatives.

Qualifications

Minimum Job Requirements

• 1-3 years of experience in healthcare payer relations, specifically focused on managed care negotiation and credentialing support

Knowledge, Skills, and Abilities

• Associate's degree in Business, Healthcare Administration, or related field preferred.
• Previous managed care experience preferred.
• Strong and demonstrated time management skills with ability to handle multiple tasks in a deadline driven environment.
• Knowledge of managed care and credentialing.
• Problem solving skills to proactively and independently address issues/asks using imaginative, innovative, and analytical approach.
• Demonstrated ability to develop strong and collaborative relationships.
• Excellent communication, organization, and interpersonal skills.
• Strong knowledge in Microsoft Excel, Word, Access, and PowerPoint.
• Skilled in analytics and decision support.
  

Job :

Primary Location :

Department :

Job Status