Provider Enrollment & Cred Rep

Reports to the Manager, Provider Enrollment & Credentialing. Responsible for the timely completion of initial and re-credentialing for Beacon Health System, which includes Beacon Medical Group (BMG) physicians and employed allied health providers, as well as physicians and allied health providers for Memorial Hospital of South Bend, Elkhart General Hospital, Beacon Health Ventures, Beacon Health LLC, and all Community Health Alliance (CHA), and Credentialing Verification Organization (CVO Alliance) contracted providers. Coordinates efforts with physicians and providers, credentialing agencies, regulatory agencies, payors, office managers and contracted providers to complete the credentialing process in accordance with the National Committee on Quality Assurance (NCQA) standards and departmental policies and procedures. Develops systems to review applications for provider and facility credentialing.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other job-related assignments and special projects as directed.

Ensures the timely completion of credentialing activities for Beacon Health System providers in accordance with NCQA and established departmental policies and procedures by:

• Coordinating efforts with outside credentialing agencies, regulatory agencies, payors, office managers, and contracted providers.
• Completing the credentialing process in accordance with NCQA/payor standards and departmental policies and procedures.
• Preparing letters of acceptance; also reporting deficiencies.
• Serving as a liaison and communicating with the CHA Medical Director on credentialing status.
• Acting as a liaison for the CHA/MMA (Michiana Medical Associates) Credentialing Committee by preparing charts, taking minutes and attending CHA Credentialing Committee meetings.
• Developing systems to review applications for CHA-contracted facilities credentialing.
• Completing Primary Source Verifications for CVO Alliance customers in accordance to their accreditation standards (JACHO, AAAHC, URAC, etc).
• Scheduling & monitoring delegation audits on behalf of CHA and CVO Alliance.
• Checking appropriate web-sites for information relevant to credentialing and verification of information.
• Notifying various entities of the physicians and providers effective and termination dates.
• Serving as a liaison and communicating with the Physician Recruitment team (BMG).
• Communicating with physicians and providers on credentialing status and requesting additional information required to facilitate the credentialing process.
• Coordinating with the Beacon Health System physicians and providers the retrieval of applicable documents and licensing information.
• Follows a strict schedule for follow up with the provider and reporting of this information to appropriate internal and external contacts before a start date for the physician or provider is assigned.
• Completing various insurance and government applications on behalf of the Beacon Health System physicians and providers.
• Notifying Beacon Health System management of any unanticipated delays and/or non-compliance.
• Coordinating with the hospitals Patient Accounts department to enroll the hospitals and providers in out-of-state Medicaid plans.
• Maintaining accurate information on Beacon Health System physicians and providers in the ECHO provider database.
• Educating new physicians and providers, along with the BMG residents, on the importance of credentialing and providing information needed to comprehend the State and Federal licensure process and associated deadlines.
• Providing timely reports as requested.
• Maintaining accurate and complete files on Beacon Health System physicians and providers.
• Maintaining each provider's CAQH on-line profile and providing updated information to CAQH on a timely basis as requested.
• Serving as administrator for various payors and insurance companies websites to provide maintenance of Beacon Health System physicians and providers information.
• Applying for and maintaining the Beacon Health System physician and provider NPPES (National Plan & Provider Enumeration System) identifier as required by HIPAA.
• Assisting Beacon Medical Group, and the hospitals Patient Accounts departments with network and claim issues related to credentialing.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma (or equivalent); an Associate's Degree in Business, Health Administration or a related field is preferred. Three years of related credentialing experience and/or experience in the healthcare or health insurance industry is desired.

Knowledge & Skills

• Requires a working knowledge of federal, state and local laws and NCQA standards applicable to assigned areas of responsibility.
• Demonstrates the analytical, problem-solving and organization skills necessary to develop and implement methods and procedures for improving and facilitating the credentialing processes.
• Requires solid office skills (including the ability to take minutes at meetings) and the ability to operate standard office equipment. Also requires basic math skills.
• Demonstrates proficient computer skills (data entry, word processing and spreadsheets). A basic understanding of database applications is desired.
• Demonstrates excellent communication skills (both verbal and written).
• Requires the interpersonal skills necessary to interact effectively with a wide variety of internal and external contacts. Also requires the ability to develop and maintain effective working relationships.

Working Conditions

• Works in an office environment.
• Requires the ability to work flexible hours, which may vary according to the department's needs.

Physical Demands

• Requires the physical ability and stamina to perform the essential functions of the position.