Revenue Integrity Credentialing Specialist

1 week ago

Jackson, Mississippi, United States West Tennessee Healthcare Full time
Job Title: Revenue Integrity Credentialing Specialist

We are seeking a highly skilled Revenue Integrity Credentialing Specialist to join our team at West Tennessee Healthcare. As a key member of our revenue cycle team, you will play a critical role in supporting management in all aspects of the credentialing and re-credentialing processes for our organizational providers.

Key Responsibilities:
  • Coordinate initial provider enrollment processes with administration and organizational provider representatives.
  • Maintain and evaluate the timeliness of detailed credentialing information in various systems and online databases.
  • Prepare, review, and submit credentialing and re-credentialing applications as required by insurance payers.
  • Analyze specific payer and contract requirements, including applications, forms, supporting documentation, and timelines.
  • Monitor and perform follow-up on pending applications, forms required, and other correspondence via phone, email, internet, and other available resources.
  • Obtain 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.
  • Communicate provider participating status to administration and organizational provider representatives.
  • Update credentialing database and project management tools to reflect information received via payer communication.
  • Evaluate and make recommendations on issues pertaining to the enrollment process to maximize the use of organizational resources and improve organizational efficiency.
  • Assess any reimbursement issues related to provider enrollment and communicate findings to revenue cycle leadership.
  • Provide 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.
  • Monitor, predict, and develop action plans for potential and actual trending payer opportunities.
  • Retain, update, and store credentialing documents for all providers as required by retention guidelines.
  • Ensure all supporting documentation is acquired and renewed with payers on a timely basis.
  • Update and maintain current payer manuals and reference materials pertaining to provider enrollment and credentialing.
  • Serve as a liaison between providers, organizational provider representatives, payers, and administration for provider enrollment and credentialing.
  • Provide accurate credentialing information upon request for verification.
  • Represent the organization at monthly operations meetings.
  • Research and maintain current knowledge of changing payer enrollment landscape, including clinic versus hospital versus behavioral health requirements and others as directed by management.
  • Resolve and/or research 'provider enrollment related' system billing edits, claim errors, claim rejections, and/or denied claims in a timely manner.
  • Identify and/or research problem 'provider enrollment related' accounts and assist with work towards timely resolution.
  • Work with clinical and other support departments to get corrections made to charges and claims to receive prompt and maximum payment.
  • Ensure 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.
  • Attend in-services, classes, and meetings related to job functions, including mandatory annual Billing and Coding Compliance training in accordance with the WTH Compliance Plan.
  • Work closely with department management and hospital departments to identify and resolve 'provider enrollment related' billing and collection issues.
  • Identify trends in 'provider enrollment related' billing and collection activity and report any observed or suspected deviation from policies or from Medicare, Medicaid, or other insurance regulations immediately to the department management.
  • Investigate and respond to questions or requests for additional information from patients/guarantors, providers, administration, attorneys, and all other authorized parties in a timely and professional manner.
  • Utilize 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.
  • Gather data, summarize, and prepare reports for management and complete special projects as assigned.
Requirements:
  • High School Diploma required; completion of Bachelor's degree preferred.
  • At least twelve (12) months of healthcare-related experience (physician office, business office, and medical staff office) required.
  • 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.

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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