Job Description
Description Summary:
Implements and maintains WCHN credentialing department processes and standards to assure compliance with all third party payers including Commercial, Medicare and Medicaid programs. Credentials and re-credentials all WCHN physicians and allied professionals. Responsible for providing credentialing reporting and ongoing support to WCHN administration and providers.
Responsibilities - Responsible for the credentialing, re-credentialing process and notification of changes including privileges, specialty, contact information, demographic information, and/or provider identification numbers. Ensures that credentialing records are maintained in an accurate and 100% complete status at all times. Work with third party payers to insure that provider rosters and locations are current. Responsible for reporting payer credentialing status to WCHN management. Makes suggestions for enhancements/changes to comply with any changes in federal or other accreditation agency requirements as appropriate.
- Ensures that organization is in compliance with all credentialing regulatory requirements and national standards established by various third party payers including CT Department of Health Services and regulatory requirements for the Centers for Medicare & Medicaid services and state requirements. This includes completing Commercial payer, Medicare and Medicaid applications for all WCHN providers as well as those community providers that serve in WCHN clinics.
- Development of standardized reporting, data collection and verification. Updates all credentialing dashboards and reporting, including WCMG provider roster and demographic info, payer credentialing/contracting guidelines, maintains and distributes all credentialing status updates, maintains Pecos/Nppes NPI reporting, as well as any other reporting requests from WCHN leadership. Maintains Med Kinetics provider enrollment database with all required information.
- Responsible for maintaining delegated status for all commercial payers i.e. Aetna, United/Oxford, Anthem, Cigna, etc. and delegated credentialing agreements signed by WCHN to assure timely participation in their respective provider networks.
- Participates in WCHN payer meetings to resolve outstanding issues or disputes related to credentialing. Responsible for reviewing claim issues involving payer and WCHN credentialing holds and/or payer issues.
- Group and individual CT & NY Medicare enrollments and revalidations and Medicaid enrollment/re-enrollment. CT license updates for New York Medicaid for the Pathology and Hospitalist providers.
- Serves as resource to the WCHN departments and physician offices in regard to standards and requirements of credentialing. Enhances professional growth and development through participation in educational programs, current literature, in-house meetings and workshops.
- Athena responsibilities include maintenance of credentialing enrollment table, client enrollment dashboard, credentialing reporting, and correspondence dashboard.
- Responsible for CAQH attestations and Meaningful Use registrations.
- Fulfills all compliance responsibilities related to the position.
- Performs other duties as assigned.
Education: ASSOCIATE'S LVL DGRE
Other Information Required: Associate Degree and minimum of three years of job-related experience. High School Diploma and 7+ years experience in lieu of Associates Degree. Desired but not required: NAMSS Certified Provider Credentialing Specialist (CPCS) Certification
Minimum Experience: three years
Desired: In-depth understanding of physician credentialing process. Understanding of Joint Commission and NCQA requirements related to credentialing. Excellent organizational and record keeping skills.
Company: Nuvance Health
Org Unit: 1784
Department: Payer Relations
Exempt: No
Salary Range: $20.86 - $38.73 Hourly
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