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Provider Credentialing Coordinator

2 months ago

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

POSITION SUMMARY

The Provider Data Entry Specialist plays a crucial role in the accurate entry and upkeep of extensive provider demographic and credentialing information sourced from various channels into the provider database of Care N Care Insurance Company of North Carolina. This position also encompasses additional supportive tasks as needed, including audits and special initiatives.

KEY RESPONSIBILITIES

  • Collect, evaluate, and process initial and re-credentialing applications for physicians, facilities, and ancillary services by conducting thorough Primary and/or Secondary Source Verification on qualifications, training, clinical privileges, experience, licensure, accreditation, certifications, malpractice history, and overall professional competence.
  • Ensure the integrity of credentialing data within the credentialing management system.
  • Generate monthly reports to track expiring certifications, licenses, and professional liability insurances, and conduct outreach to secure updated documentation.
  • Assist in the organization and execution of monthly Credentialing Meetings.
  • Prepare and dispatch monthly credentialing approval or denial notifications based on committee evaluations.
  • Act as a liaison between providers and the committee in the event of appeals regarding committee decisions.
  • Oversee and monitor delegated credentialing agreements, including conducting initial and annual audits throughout the agreement's duration.
  • Draft, review, negotiate, and finalize contracts and amendments with providers, facilities, and ancillary services to ensure a robust network that supports optimal reimbursement strategies.
  • Maintain all contracts and relevant documentation within the contracting management system.
  • Identify and recruit providers to ensure network adequacy and market presence in both existing and expanding counties.
  • Assess participation requests in relation to current and future network needs, existing contractual relationships, and access to care.
  • Provide recommendations to the Provider Oversight Committee based on comprehensive research and contract evaluations.
  • Facilitate Single Case Agreements (SCAs) as required by the Utilization Management department.
  • Support the Provider Concierge team in preparing for New Provider Onboarding, periodic In-Service meetings, and Provider Roundtables.
  • Foster effective teamwork by leading with influence to achieve established objectives within budgetary constraints.
  • Contribute to a culture of customer advocacy, continuous improvement, and high standards of service.
  • Establish and maintain positive relationships with business stakeholders, regulatory bodies, provider practices, and vendors.
  • Uphold a high level of professionalism in all interactions and communications, while performing additional duties as assigned.

EDUCATION AND EXPERIENCE REQUIREMENTS

  • Associate's Degree in business or a healthcare-related field, or three (3) years of equivalent experience in a healthcare setting.

EXPERIENCE PREFERENCES

  • A minimum of 2 years of direct experience in negotiating Medicare Advantage and/or managed care contracts.
  • At least 1 year of hands-on experience in credentialing processes.

PREFERRED QUALIFICATIONS

  • Master's degree in business or a healthcare-related discipline.
  • Certification in Provider Credentialing.
  • Experience collaborating with regulatory agencies such as the Centers for Medicare & Medicaid Services.
  • 3+ years of direct interaction with providers.
  • Market experience in the Carolinas.

SKILLS AND COMPETENCIES

Essential Skills:

  • In-depth knowledge of provider contracts, negotiation processes, payment methodologies, and claims management.
  • Understanding of Plan requirements related to sanctions and exclusions monitoring.
  • Familiarity with state and federal regulations pertaining to Medicare.
  • Comprehensive knowledge of provider operations.
  • Exceptional written and verbal communication abilities.
  • Proficiency in Microsoft Office applications.
  • Strong organizational skills with meticulous attention to detail.
  • Self-driven with excellent follow-through capabilities.
  • Aptitude for learning contracting and credentialing programs, along with reporting tasks.
  • Ability to manage multiple priorities effectively to meet deadlines.

Desirable Skills:

  • Familiarity with CAQH.
  • Experience using the Symplr platform.
  • Knowledge of value-based and ACO/risk contracting.
  • Project management experience.
  • Expertise in credentialing database management.

PHYSICAL DEMANDS

  • Ability to exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently to move objects.
  • Primarily sedentary work involving sitting, with occasional walking or standing.

ABOUT CARE N CARE INSURANCE COMPANY OF NORTH CAROLINA

Care N Care Insurance Company of North Carolina is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Care N Care Insurance Company provides Medicare Advantage plans to eligible beneficiaries in North Carolina, striving to create a supportive and inclusive work environment.