Job Purpose: To manage and lead all aspects of credentialing and enrollment for Avance Care providers in accordance to insurance standards.

Essential Duties and Responsibilities

• Oversees provider relation activities including management of provider credentialing, enrollment, provider appeals, call center related activities, reporting, and other general business operations
• Manages daily operations of functions across the provider database management driving accountability for financial and non-financial results
• Sets team direction, resolves problems, and provides guidance to organizational stakeholders. Answering questions, process requests from locations/providers related to credentialing and enrollment information
• Completes provider credentialing, recredentialing, and enrollment applications; monitors applications and follows-up as needed
• Compile and maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases. Updating each provider’s CAQH database file timely according to the schedule published by CMS
  • Sets up and maintains provider information in online credentialing databases and system
  • Tracks license and certification expirations for all providers to ensure timely renewals
  • Ensures practice addresses are current with health plans, agencies and other entities
  • Processes applications for appointment and reappointment of privileges to Avance Care
  • Tracks license, DEA and professional liability expirations for appointed ASC providers
  • Maintains ASC appointment files, and information in credentialing and enrollment database
  • Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers
  • Maintains corporate provider contract files
• Adapts departmental plans and priorities to address business and operational challenges
• Willingness to establish and maintain effective work relationships with the payers, providers, co-workers, and leadership team
• Communicate to departmental leaders, regional managers, and RCM team of provider credentialing and enrollment status updates
  • Actively address enrollment disconnects regarding facility and providers via insurance denials or out-of-network charges. Working closely with RCM for trending and remediation
• Remain knowledgeable of current health plans and agency requirements for credentialing and enrollment of providers, and any payer changes impacting providers
  • Audits health plan directories for current and accurate provider information
  
  

Additional Duties and Responsibilities

• Accomplishes all tasks as assigned or become necessary

Qualifications

Experience, Education and Licensure:

• Minimal education level for this type of role would be consistent with a Associate’s Degree, or equivalent experience
• Bachelor’s Degree in Business Administration or related, preferred
• At least 3-5 years of credentialing and enrollment experience; knowledge of Medicaid is a plus
• Experience in healthcare
• Basic understanding of National Committee for Quality Assurance (NCQA) Credentials Verification Organization services, preferred

Knowledge, Skills, and Abilities:

• Ability to read and interpret documents such as professional journals, safety rules, operating and maintenance instructions, procedure manuals, and government regulations
• Proven ability to write reports, business correspondence, and procedure manuals
• Effectively present information and respond to questions from managers, employees, clients, customers, and the general public
• Ability to interact and communicate with a variety of people, both on a one-on-one basis and in meetings and group presentations
• Keen understanding on how relate to and work with ill, emotionally upset, and sometimes hostile people; anticipating and reacting calmly to emergency situations
• Competently define problems, collect data, establish facts, and draw valid conclusions
• Ability to think logically in order to troubleshoot, analyze situations, and make appropriate decisions
• Proficient computer skills, including working knowledge of Microsoft Office Suite, e-mail systems, Credentialing and Enrollment Database management and web-based programs
• Ability to handle multiple tasks simultaneously and follow directions
• Knowledge and understanding of how for-profit medical practices run
• Knowledge and understanding of medical coding and billing

Language Skills:

Ability to communicate well in writing and in person. Ability to read and interpret common medical, billing, and business terminology.

Expectation of Employee

• Understand, follow, and enforce Avance Care’s policies and procedures, as documented in the Policy and Procedure Manual
• Maintain company confidentiality in all areas
• Develop and maintain effective working relationships with providers, employees, co-workers, and management
• Maintain the professional image and polish expected of all representatives of Avance Care
• Work at least 40 hours each week
• Work as a team player
• Pays strong attention to detail
• Uses tact in all personal interactions
• Maintains a positive and respectful attitude, energetic team spirit, and supportive company morale
• Demonstrates flexible and efficient time management and the ability to prioritize workload