Overview:

PROVIDER CREDENTIALING &RECREDENTIALING & ENROLLMENTS:

Obtaining, verifying, entering, and storing provider credentials within established timeframes and quality standards.

Ensuring required credentials are received for initial credentialing and re-credentialing.

Save credentials in established folders and uploading into Verity Stream(Credential Stream) as appropriate.

Data-enter credentials, payers, payer effectivedates, and other pertinent information, as appropriate.

Identify and forward to appropriate Coordinators items that need their attention.

Enrolling providers to the appropriate insurers.

Actively working to receive and document status and effective dates in Verity Stream (Credential Stream), Monday Board software, Issue Trak (ticketing system used internally), and other tools/software, as needed.

Responding to re-credentialing requests with required credentials per payer.

Store welcome letters/emails in the appropriate folder and upload into Verity Stream(Credential Stream) for each payer entry.

Monitor and update Monday Boards, Issue Track, and Provider Rosters related to credentialing or enrollment without being asked.

Notify offices of effective dates from each payer (forward welcome letters/emails or advise them directly from you).

CUSTOMER SERVICE/TROUBLESHOOTING:

Working interdepartmentally and externally to address issues with provider set-up, EOB research, and related information.

Actively address issues reported with payments that may not be at expected reimbursement levels.Determine if there’s an issue with the provider’s network status with the payer versus what’s in Verity Stream (Credential Stream) and showing at the office’s PMS system.

Determine if there is an issue with the proper fee schedule being attached by the payer.

Seek reprocessing claims at the payer level to support the office and avoid having to resubmit (where possible).

Approach each reported issue from the perspective of providing excellent customer service – professional communications and addressing issues from a customer service perspective.Actively help others troubleshoot issues, especially where you may have some additional knowledge (e.g., an office was previously owned by you).

PARTNERING WITH OFFICES/PROVIDERS:

Demonstrate a sense of ownership and pride in working with your assignedoffices to facilitate a positive impact in working with the credentialing department.

Oversight of assigned offices/providers; providing timely, courteous, and thorough support.

Provide consistent and timely follow-up on all outstanding items for our offices.

Build an ongoing, collaborative rapport with office staff and providers.

Ensure requests are bundled and communications appropriate (e.g.: update/request items appropriately).

FEE SCHEDULE MAINTENANCE:

Working interdepartmentally and externally to ensure appropriate fee schedule attachment (to provider records with payers) and updating into office practice management systems.

During provider enrollment, ensure the insurer attaches the appropriate fee schedule (e.g., mirroring other providers or, if a specific schedule, obtaining the schedule and notifying payers, per the current process).

Monitor, update, and process fee schedule updates from Monday Board software and emails proactively.

Work with Payer Strategy after the negotiation process to ensure new fee schedules received are attached to providers (notify payers, as the process may indicate).

Store fee schedules in the appropriate folder with the proper names

Update office PMS systems accurately and within established timeframes.

REQUIREMENTS:

High school diploma or equivalent.

1+ years of job experience preferred:Dental or health experience is a plus, but it is not required.

Dental or health insurance enrollment/credentialing experience (PPO/HMO/Medicaid, EPO, DiscountPlans, etc.) is preferred but not required.

Proficient with MicrosoftOffice (Word, Excel & Email – Outlook), Adobe Pro, and an ability to learn new computer applications.

Verity Stream credentialing software experience is a plus but not required.