Health Partners Credentialing

Job Category:

Work Shift/Schedule:

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

This position shall perform the day–to-day duties and tasks related to the credentialing of practitioners and facilities to participate with the Health Partners (HP) Network. This includes the processing of all initial appointments and re-appointments and supplying all HP contracted payers with provider information deemed necessary to process and pay claims accurately and to support an accurate provider roster. Works in partnership with the Quality Specialist, the Provider Relations Representative and the Central Verification Office (CVO) to achieve mutual objectives. Enrolls providers with various payer groups as directed to include initial enrollment and re-credentialing to ensure continued participation. 

• Licensure or other certifications:

• Educational Requirements: Bachelors Degree

• Minimum Experience: Minimum two (2) years credentialing experience in a managed care organization, hospital or physician environment. Proficient in MS Office products.

• Other:

• Preferred Licensure or other certifications: CPCS certification

• Preferred Educational Requirements:

• Preferred Experience: Knowledge of NCQA standards

• Other:

• Strong organizational skills required with the ability to perform multiple projects

• Excellent interpersonal skills, along with strong presentation and team facilitation skills

• Solid understanding of the goals and objectives of the department

• Represents the organization in a professional and businesslike manner

• Must maintain the confidentiality of information relative to Northeast Georgia Health System, its providers, members and other constituents

• Demonstrates the ability to organize, prioritize and maintain a coordinated process for the collection and verification of credentialing data

• Performs all aspects of the application process (initial and reappointment) for Health Partners by reviewing applications for compliance with the established eligibility criteria and for completeness and accuracy. Follows departmental process to ensure the supporting documentation is complete and signed prior to initiating the credentialing process. 

• Credentials all practitioners and facilities interested in participating with Health Partners according to NCQA standards and the approved Health Partners credentialing program.

• Conducts primary source verification of credentials to include verification of licensure, licensure sanction activity, DEA certificate, work history, professional liability insurance, education, training & board certification, hospital privileges to include disciplinary action history, NPDB query and professional references in accordance with credentialing program. Follows proper documentation practices and maintains provider files in an orderly and secure fashion.

• Initiates contact with the applicants and their staff for orientation and educational purposes. Schedules meetings with applicants to facilitate the on-boarding process.

• Follows the facility needs assessment process in determining facility eligibility and communicates findings to management according to policy.

• Coordinates activities related to the Health Partners Credentials Committee to include preparation and distribution of Credentialing Committee reports. On a monthly basis, or as scheduled, prepares documents and committee packets for presentation to the Credentialing Committee. This includes the agenda, applicant profiles, site visit scores, previous minutes and other information as deemed necessary.

• Participates in the Credentials Committee meetings. Takes minutes as assigned, drafts and distributes them to the Credentials Committee members for review and approval.

• Coordinates and processes the entry of credentialing related information in to the appropriate software application in a timely and accurate fashion, ensuring integrity of the information by password protecting appropriate information and documents.

• Following the post approval process, the provider is notified of the committee’s decision by way of letter and specific organizational documents are amended and distributed to key personnel as outlined in departmental policy. Other post approval processes are completed following departmental procedure and include enrollment in HP contracts.

• On an ongoing basis, tracks timeliness of provider loads by payer to include date submitted, date confirmation received, error rate and corrections needed. Reports non-compliance to manager for further direction. Retains communication with payers for reference purposes.

• On a monthly basis, audits provider loads once confirmed by the payer for accuracy. Report, by way of written correspondence, the errors that need to be corrected to the payer. Report findings to management. Monitor progress and resolution. Schedule conference call and/or meetings with payer representatives to address issues.

• Monitors receipt of payer effective date notices. Contacts payers to follow-up on enrollment status, secure provider numbers, effective dates and confirmation letters. Enters effective dates and provider numbers on the payer grid application (Medicred software). Scans approval letters into each provider's file for reference purposes. Notifies key personnel when updates are made.

• Participates in the quarterly demographic update process, following up as deemed necessary.

• Takes the lead with payers in monitoring the progress of payer enrollment for NGPG providers. Notifies management of payer noncompliance.

• Resolves any issues that may arise in regard to provider to payer enrollment processing. Corresponds with different departments throughout NGHS to resolve issues that are enrollment related.

• Enters and updates all NGPG provider demographics into hospitalist group database for tracking and reporting purposes following established procedures. 

• Updates enrollment confirmations and changes to enrollment and hospitalist group databases as they are received from the providers.

• Actively participates in the NCQA accreditation process to include preparation, submission and the on-site survey.

• Acts as a liaison between the Health Partners, providers, employers, payers and Medical Staff Services (Central Verification Office).  

• Assists with invoicing and collecting the annual HP participation fees from providers.

• Maintains regulatory compliance and promotes quality customer service.  Ensures provider satisfaction issues regarding noncompliance with credentialing program are investigated, reported and appropriate action is taken to resolve issue. Reports ongoing controversial issues to management.

• Follows proper documentation practices and maintains provider files in an orderly, secure fashion.

• Assists in obtaining signed confidentiality agreements and conflicts of interest statements annually from HP committee members and staff and retained for reference purposes.

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65%of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.