Revenue Integrity Credentialing Specialist

Category:
Admin Support

City:
Jackson
State:
Tennessee
Shift:
8 - Day (United States of America)

Job Description Summary:
This position is responsible for supporting management in all aspects of the credentialing and re-credentialing processes for organizational providers. Requires working knowledge of the Revenue Cycle and the importance of evaluating and securing all appropriate information between the providers and the health plans to maximize reimbursement to the health system. The Revenue Integrity Credentialing Analyst must have expert knowledge in credentialing and re-credentialing processes with major organizational networks to include: Medicare, Medicaid, TennCare MCO's, BCBS, Cigna, Aetna, United Healthcare, PHCS, Tricare. The Revenue Integrity Credentialing Analyst must also have knowledge of accounting, healthcare, general office procedures, standard PC word processing, payer website navigation, and spreadsheet applications, and be capable of communicating clearly and concisely, both verbally and in writing, with peers, supervisors, payers, physicians, patients, other departments, etc. The Revenue Integrity Credentialing Analyst is responsible for working with multiple payers' representatives in issue resolution, screening provider applications for additional information requirements, resolving outstanding credentialing issues, managing correspondence with payers and providers to ensure timely applications' processing and continuously working to improve aging of outstanding applications while minimizing controllable losses. This position assumes the clinical and financial risk of the organization when enrolling providers into organizational networks. Additional responsibilities include reconciling pending application records with pending claim inventories, assisting patients and organizational departments with network participation questions, and timely monitoring of CMS databases for upcoming provider revalidation processes. The Revenue Integrity Credentialing Analyst works directly with customers, physicians, and payer representatives to provide information and resolve issues in a highly responsive manner. Commitment to customer service and process improvement are critical to this position, as are communication and conflict resolution skills. The Revenue Integrity Credentialing Analyst must complete all initial and annual training relevant to the role and comply with all relevant laws, regulations, and policies.

Responsibilities

• Coordinates initial provider enrollment processes with the administration and organizational provider representatives to include: completion of provider information packets, proper provider documentation for credentialing purposes, e.g., work history, state license, DEA, board certifications, etc.
• Maintains and evaluates the timeliness of detailed credentialing information in the various system and online databases, spreadsheets, and shared drives.
• Prepares, reviews, and submits credentialing and re-credentialing applications as required by insurance payers.
• Analyzes specific payer and contract requirements, e.g., applications, forms, supporting documentation, and timelines.
• Monitors and performs follow up on pending applications, forms required and other correspondence via phone, email, internet, and other available resources.
• Obtains necessary approvals within the timeframe set forth by management and payer guidelines, including provider numbers, effective dates, and group information essential to the billing process.
• Communicates provider participating status to administration and organizational provider representatives.
• Updates credentialing database and project management tools to reflect information received via payer communication.
• Evaluates and makes recommendations on issues pertaining to the enrollment process in order to maximize the use of organizational resources and to improve organizational efficiency.
• Assesses any reimbursement issues related to provider enrollment and communicates findings to revenue cycle leadership.
• Provides detailed status reports on pending providers, as well as any pending payer issues on a monthly basis to revenue cycle leadership and other organizational representatives.
• Monitors, predicts and develops action plans for potential and actual trending payer opportunities.
• Retains, updates and stores credentialing documents for all providers as required by retention guidelines.
• Ensures all supporting documentation is acquired and renewed with payers on a timely basis.
• Updates and maintains current payer manuals and reference materials pertaining to provider enrollment and credentialing.
• Serves as a liaison between providers, organizational provider representatives, payers, and administration for provider enrollment and credentialing.
• Provides accurate credentialing information upon request for verification.
• Represents the organization at monthly operations meetings.
• Researches and maintains current knowledge of changing payer enrollment landscape including clinic versus hospital versus behavioral health requirements and others as directed by management.
• Resolves and/or researches 'provider enrollment related' system billing edits, claim errors, claim rejections, and/or denied claims in a timely manner. Identifies and/or researches problem 'provider enrollment related' accounts and assists with work towards timely resolution. Works with clinical and other support departments to get corrections made to charges and claims to receive prompt and maximum payment.
• Ensures hospital, federal, and payer compliance guidelines related to provider enrollment, credentialing, or re-credentialing are met.
• Responsible for the analysis and processing of correspondence regarding 'provider enrollment related' rejections.
• Attends in-services, classes, and meetings related to job functions to include mandatory annual Billing and Coding Compliance training in accordance with the WTH Compliance Plan.
• Works closely with department management and hospital departments to identify and resolve 'provider enrollment related' billing and collection issues. Identifies trends in 'provider enrollment related' billing and collection activity and reports any observed or suspected deviation from policies or from Medicare, Medicaid or other insurance regulations immediately to the department management.
• Investigates and responds to questions or requests for additional information from patients/guarantors, providers, administration, attorneys, and all other authorized parties in a timely and professional manner.
• Utilizes systems, tools, and department resources to achieve production and quality targets for resolution of outstanding credentialing applications.
• Demonstrate proficiency in the completion of credentialing processes for the following organizational networks: Medicare, Medicaid, Tenncare (MCO's), BCBS, Cigna, Aetna, PHCS, Tricare, and United Healthcare.
• Gathers data, summarizes and prepares reports for management and completes special projects as assigned.

Qualifications

EDUCATION:

• High School Diploma required; completion of Bachelors degree preferred.

LICENSURE, REGISTRATION, CERTIFICATION:

• N/A

EXPERIENCE:

• At least twelve (12) months of healthcare-related experience (physician office, business office, and medical staff office) required.

KNOWLEDGE, SKILLS, ABILITIES:

• Requires knowledge of credentialing, enrollment process.
• Requires expert-level organizational skills, attention to detail, and communication skills to clearly and concisely communicate verbally and in writing with peers, managers, payers, physicians, patients, and other departments.
• Requires superior ability to prioritize and manage multiple and concurrent ongoing tasks simultaneously.
• Requires strong problem solving skills to address payer and patient issues appropriately and know when to ask for assistance.
• Requires working knowledge of the Revenue Cycle process.
• Requires working knowledge of the reimbursement and regulatory environment so as to ensure compliance regarding 'provider enrollment related' issues.
• Requires working knowledge of insurance regulations, managed care practices, regulatory agencies and alternative funding sources.
• Must maintain a high level of customer (both internal and external) responsiveness.
• Ability to work in a fast paced environment and remain flexible under stressful situations.
• Requires knowledge and ability to run multiple computer applications simultaneously.
• Knowledge and general understanding of medical coding systems preferred.
• Ability to understand, make changes, and apply complex and detailed guidelines and other instructions to meet regulatory mandates and ensure that the hospital receives maximum reimbursement.
• Proficient use of Microsoft Office products, including Word, Access, Excel, Outlook, and internet.

NONDISCRIMINATION NOTICE STATEMENT

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.

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