Nuvance Health Careers

Description

Summary:

The position is a professional role that requires a high level of expertise and knowledge in hospital and medical group credentialing and payer enrollment functions. The role manages the credentialing process for existing and new providers and ensures compliance with all relevant standards including but not limited to Medicare, Medicaid, and Tricare. Works directly with physicians/allied providers and 3d party payers to enroll provider for network participation. Responsible for fostering effective relationships and communications with operational leadership, physicians, revenue cycle, payers, and hospital partners. 

Responsibilities:

1.Manages and maintains multiple provider PECOS, CAQH, National Practitioner Data Base (NPDB) and National Plan and Provider Enumeration (NPPES) accounts.

2. Monitors the accuracy and turnaround times of active credentialing applications and holds payers accountable to comply with contractual language and state law requirements related to enrollment timeframes.

3.Evaluates and revises front-end processes as needed to support a positive provider experience as well as efficient and accurate credentialing.

4. Responsible for provider primary source verification including required fact checking with various certification boards and agencies.

5. Audits applications and licensing documentation for accuracy.

6. Works directly with Revenue Cycle department on effective dates, release of bill holds and any Cerner updates for new providers.

7. Accountable for reporting and meeting key performance indicators (KPIs).

8. Communicates directly with providers, payers, practice managers, and on-boarding staff as needed.

9. Manages and maintains multiple provider demographics information with multiple health plans.

10. Proactively solve problems, administrative issues, or provider requests in a timely manner.

11. Performs other duties as assigned.

 Other Information:

Essential:
* Associate's Level Degree, or 10+ years work related experience in lieu of degree. 

Bachelor’s Degree preferred in business, healthcare related field

5 years of relevant payer contract support, credentialing and/or enrollment experience

Strong detail orientation and high work quality standards.

Knowledge of Medicare/Medicaid regulations, PPO, and HMO arrangements, third party payer protocols, and medical terminology.

Understanding current healthcare laws and regulations.

Medical licensing and certification requirements.

Knowledge of NCQA and URAC standards.

Excellent written and verbal communications skills.

Strong organizational skills.

Proficiency in Excel, Word, PowerPoint, Outlook, and database applications required.

High level of critical thinking and problem-solving skills.

Credentialing Specialist (CPCS) Certification desired.

NAMSS Certification preferred.

Working Conditions:

Manual: significant manual skills/motor coord & finger dexterity

Occupational: Some occupational risk

Physical Effort: Medium to Heavy effort. May exert up to 35 lbs. force

Physical Environment: Some exposure to dirt, odors, noise, human waste, etc.

Company: Nuvance Health

Org Unit: 1784

Department: Payer Relations

Exempt: No

Salary Range: $24.92 - $46.28 Hourly