Revenue Integrity Credentialing Specialist

Revenue Integrity Credentialing Analyst

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

Process 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.

Monitor, predict and develop 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.

Customer Service Assists customers regarding 'provider enrollment related' billing questions and ensures appropriate resolution of problems.

Keeps updated on changes with regulatory issues.

Communication Serves as contact for others regarding 'provider enrollment related' questions/account issue resolution.

Mentors and trains other staff as necessary regarding 'provider enrollment related' matters.

Communicates daily via the telephone or written communication with payers, patients, departments to obtain and provide all information for payers to process outstanding enrollment applications and pay claims quickly and accurately.

Other Takes personal accountability for professional growth and development.

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.