Title: Enrollment & Credentialing Representative
Location: Midtown
Org Unit: Enrollment
Work Days:
Weekly Hours: 35.00
Exemption Status: Non-Exempt
Salary Range: $36.76 - $42.25
*As required under NYC Human Rights Law Int [redacted] - Salary range for this role when Hired for NYC Offices
Position SummaryUnder supervision, analyzes and resolves problems related to physician enrollment into managed care plans for full time faculty and IPA physicians. Ensures that physicians are linked correctly to plans and products for correct claims payment and revenue. Acts as a liaison between the Managed Care Payers, and the Academic Clinical Providers and their dedicated representatives with the Academic Clinical Departments.
Job Responsibilities- Assists with following up on physician enrollment status with group contracted managed care plans by building effective relationships with plan representatives to ensure that PO faculty and IPA member activities are given priority processing.
- Assists in evaluating reported claim problems to determine if problem is related to linkage or other error.
- Identifies data disparities between group contracted plan sources and Managed Care database to limit negative impact on revenue, precertification and referral denials and patient procedure cancellations. Works with plan representatives to correct errors.
- Identifies delays in credentialing, linkage errors and claims payment problems and works with plan representatives to further identify root causes and resolve problems.
- Communicates with our clinical providers and the clinical departments for the detailed collection, review, and compilation of information for new faculty intakes and recredentialing procedures.
- Maintains individual physician file folders according to credentialing policies and procedures with initial and recredential applications and credential verifications which are reviewed during delegation audits by managed care plan representatives.
- Maintains internal database and external web module database; updates physician information in group contracted managed care plans, Medicare, Medicaid, and non- contracted carriers including demographic information, addresses changes and disenrollments.
- Maintains enrollment and credentialing for delegated and non-delegated plans, Medicare, and Medicaid including but not limited to enrollment, disenrollment and demographic changes.
- Processes Intake Applications, enters data and follows credentialing policies and procedures for delegation including but not limited to primary source verification.
- Reviews Initial and Recredentialing files in preparation for Delegated Managed Care Committee Meetings, Plans and NCQA Audits. Produces status reports and reconciliations to be sent out.
EducationExperienceAt least 1 year of related experience. Knowledge and experience with Excel a must. Able to perform essential functions for reporting purposes and data analysis (ie. Create spreadsheets, insert delete manipulate save data, data sorting filtering for plan-database comparisons and reconciliations). Previous experience in medical professional credentialing. Strong project management skills.
Knowledge, Skills and Abilities- Demonstrated experience with relational database and supporting software including Microsoft Word, Excel and Microsoft Access.
- Excellent problem solving, communication and interpersonal skills to effectively mediate and resolve issues in a timely and cost-effective manner.
- Demonstrated project management skills.
- Demonstrated ability to prioritize workflow to achieve time sensitive goals.
Licenses and CertificationsWorking Conditions/Physical Demands
