Provider Credentialing Specialist I
2 months ago
About us:
Lumen Solutions Group Inc., a dynamic small and minority-owned, Disadvantaged Business Enterprise headquartered in Florida, USA
As a leading consulting services and solutions provider, we focus on IT Staffing, Business/IT Strategy, Business Process Blueprints, Enterprise Architecture, Enterprise Transformation for our clients
Our client base includes Fortune 500, Government, non-profit and emerging growth companies.
Job Description:
PURPOSE:
This role will credential practitioners for network participation with *** Client and accurately maintain all provider data within the enterprise-wide Provider file to supply the organization with provider data, while ensuring compliance with regulatory, accreditation, legal and company requirements and standards.
ESSENTIAL FUNCTIONS:
40% Analyzes credentialing applications to perform the primary source verification of the appropriate credentials in order for a practitioner to participate in the *** networks
Once verified, accepted and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.
30% Responds to external and internal inquiries regarding provider participation eligibility and criteria, participation status, credentialing, contractual status and provider file updates
Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved
Professional etiquette, communications and sound decision making is required.
15% Maintains the provider file, the Provider Information Control (PICS) inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, recredentialing, demographic updates, terminations and all other provider file maintenance activities.
10% Responsible for identifying, analyzing and resolving immediate and existing provider file issues
Processes provider file inputs in accordance with applicable state laws and departmental guidelines
Verification of provider data and system release entered into the provider file database, ensuring a successful integration with the other corporate systems.
5% Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily
The requirements listed below are representative of the knowledge, skill, and/or ability required
Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: High School Diploma
Experience: 3 years physician credentialing experience or health insurance/managed care operations experience in a customer service, claims, billing and enrollment, or call center environment.
Preferred Qualifications: Bachelor s Degree in Business, Healthcare Administration or related field
Knowledge, Skills and Abilities (KSAs)
Must be proficient in the use of Excel spreadsheets, and an understanding of Pivot tables., Proficient
Excellent verbal and written communication and interpersonal skills
Ability to develop and maintain effective relationships with peers, physicians, and medical staff to create confidence, respect and dependability., Proficient
Knowledge of medical terminology, Proficient
Demonstrated proficiency utilizing reference materials and ability to follow Standard Operating procedures to reduce risk and ensure provider data accuracy and overall quality., Proficient
Ability to understand jurisdictional requirements and the legal ramifications of the credentialing and provider file maintenance processes and interpret reasoning for performing verification and/or appropriate actions., Proficient
The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs
Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Licenses/Certifications: Certified Provider Credentialing Specialist (CPCS) Pref
***Lumen and / or its clients will not provide equipment (Laptop, monitor, etc.) to the selected contractor
The contractor must have their own equipment
Access to a virtual desktop set up (software) will be provided by Lumen s client, allowing the user access to the required systems and technology
***
Lumen Solutions Group Inc
is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.
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