Contracting and Credentialing Specialist

4 weeks ago

Greensboro, United States Care N Care Insurance Company of North Carolina Full time
Job DescriptionJob Description

JOB SUMMARY

The Contracting & Credentialing Specialist initiates, negotiates, and executes Medicare Advantage (MA) physician, hospital, and/or other provider contracts and agreements. The Contracting & Credentialing Specialist also obtains, reviews, and processes physician, facility, and ancillary initial & re-credentialing applications and supporting documentation to approve credentialing and health plan participation.


ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Draft, review, negotiate, and execute provider, facility, and ancillary contracts and amendments to ensure a high-quality network that helps ensure appropriate reimbursement methodologies are in place (performance incentives, capitation, per diems, creative reimbursement, etc.) to maximize quality and cost savings.
  • Maintain contracts and documentation within a contracting system.
  • Identify and recruit providers based on network adequacy and marketability in existing and expansion counties.
  • Evaluate participation requests against network needs, current contractual relationship, expansion efforts, access to care.
  • Make recommendations to the Provider Oversight Committee based on research and contract as requests are approved.
  • Complete Single Case Agreements (SCAs) as requested by the Plan’s Utilization Management department.
  • Obtain, review, and process physician, facility, and ancillary initial and re-credentialing applications by completing Primary and/or Secondary Source Verification on education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, and professional competence.
  • Maintain credentialing data within a credentialing system.
  • Pull monthly reporting to identify expiring certifications, licenses, professional liability insurances, etc. and complete outreach to obtain current/updated documentation and information.
  • Assist Manager of Network & Provider Services with preparation, set up, and execution of monthly Credentialing Meetings.
  • Fulfill monthly credentialing approval and/or denial letters based on committee’s review and final decision.
  • Serve as liaison between provider and committee when/if an appeal regarding a committee decision is received.
  • Maintain and monitor delegated credentialing agreements, including performing initial and annual audits for the life of the agreement.
  • Assist Provider Concierge team in preparing for New Provider Onboarding, periodic In-Service meetings, Provider Roundtables, etc.
  • Builds effective teams by leading with influence, (both internally and externally) to achieve established goals and within established budgets.
  • Contribute to a culture of customer advocacy, continuous improvement, and exceptionally high standards
  • Establish and maintain a positive working relationship with shareholders, regulatory agencies, and vendors
  • Maintains a high level of professional standards with interactions, communications and
  • Performs other duties as assigned


EDUCATION AND EXPERIENCE

Education:

  • Bachelor’s Degree in business, or other healthcare-related field or five (5) or more years equivalent healthcare work experience

Required Experience:

  • 2-5 years’ experience in negotiating Medicare Advantage and/or managed care contracts with physician, hospital, facility, ancillary and/or other provider contracts
  • 1 or more year of Medicare Advantage provider relations and/or provider network management experience

Preferred Experience:

  • Master’s degree in business or other healthcare-related fields
  • Credentialing experience in healthcare
  • Experience working with regulatory agencies such as the Centers for Medicare & Medicaid Services
  • 3+ years of direct provider interaction

KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

  • Knowledge of provider contracts, contract negotiations, provider payment methodologies, claims payment, and provider set up.
  • Excellent written and verbal communication skills
  • Proficiency in MS Office applications
  • Self-motivated with excellent follow-through
  • Ability to learn contracting & credentialing program; ability to complete reporting
  • Ability to manage multiple priorities and prioritize workload to ensure deadlines are met.

Preferred Competencies:

  • Familiar with CAQH
  • Knowledge of value-based contracting
  • Knowledge of ACO/risk contracting
  • Knowledge of provider practice and ancillary provider operations
  • Knowledge of local provider community
  • Project management


PHYSICAL REQUIREMENTS

  • Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
  • A negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
  • Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
  • Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.


ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.


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