Job Summary:

The Credentialing Specialist -Provider Enrollment position acts as a liaison between providers, revenue cycle and practice operations making sure that all providers are set up correctly with payers. The Credentialing Specialist - Provider Enrollment position is responsible for providing administrative support for the process of payer enrollment credentialing for the medical staff at Westchester Medical Center Advanced Physician Services. Primary responsibility of this position is ensuring that all physicians and allied health professionals are payer enrolled and set up accurately with contracted payers. Work is performed in compliance with detailed requirements, guidelines, and deadlines of Centers for Medicare & Medicaid Services, National Committee for Quality Assurance (NCQA) in collaboration with WMCHealth Network Medical Staff Offices, accrediting organizations, and regulatory agencies. Does related work as required.

Responsibilities:

• Process applications and recred applications for healthcare providers seeking to enroll with various insurance networks, ensuring accurate and timely submission.
• Verify the credentials of healthcare providers, including education, training, and licensure, to meet insurance network and regulatory requirements.
• Handling application procedures, gathering information, reviewing, and verifying requirements, processing applications, and effectively communicating with providers daily.
• Evaluating provider payer status to determine options and next steps of enrollments with different payers and agency programs based on providers current enrollment status.
• Assessing eligibility of providers for specific programs, making recommendations, and maintaining meticulous records of all provider files.
• Pay close attention to new provider onboarding tracker; ensures payer enrollment, credentialing process, and demographics are processed in a timely manner.
• Review and maintain provider data in the enrollment databases/rosters, ensuring all information is current and accurate for billing and credentialing purposes.
• Requests documentation follows up on receipt of required documents, reviews documentation, updates status of application to completion.
• Supporting the Medical Staff Office by identifying, initiating, monitoring, and maintaining Medicaid and Medicare enrollment requirements.
• Ensure proper attention is given to all assigned files and perform required daily tasks in a timely manner.
• Utilization and maintenance of required credentialing related databases.
• Maintains an Excel database for tracking sensitive documents and monitoring expiring licenses and communication of required approvals.
• Responds to requests for provider information regarding credentialing status and recredentialing processes.
• Coordinate with insurance carriers to resolve any issues or discrepancies that arise during the enrollment process.
• Participates in meetings and training sessions for continued workflow efficiencies.
• Provides regular updates on work being performed.
• Protects provider information in strict compliance and confidence.
• Does related work as required.

Experience:

Five years of experience where the primary function of the position was payor enrollment credentialing.

Education:

High school or equivalency diploma, required

Licenses / Certifications:

Other:

Knowledge of medical staff credentialing processes, procedures and resources; knowledge of requirements of various organizations which affect the credentialing process such as CMS, NCQA, New York State Education Department, and New York State Department of Health; good knowledge of the requirements of Westchester Medical Center By Laws and policies regarding credentialing and privileging standards for the various clinical departments and sections; good knowledge of medical terminology; ability to assemble and organize data; ability to determine priorities and meet deadlines; ability to effectively use computer applications such as spreadsheets, word processing, calendar, e-mail and database software in performing work assignments; ability to communicate effectively both orally and in writing; ability to establish and maintain effective working relationships with professional medical, technical, managerial, clerical and non-skilled personnel; attention to detail; sound and mature judgment; flexibility.

About Us:

NorthEast Provider Solutions Inc.

Benefits:

We offer a comprehensive compensation and benefits package that includes:

• Health Insurance
• Dental
• Vision
• Retirement Savings Plan
• Flexible Savings Account
• Paid Time Off
• Holidays
• Tuition Reimbursement