Job DetailsJob Location: Dallas-Corporate - Dallas, TX 75230Position Type: Full TimeSalary Range: $50,000.00 - $60,000.00 SalaryTravel Percentage: NoneJob Shift: DayJob Category: Health CareJob Summary:
Under the direction of the Director of Credentialing & Enrollment, the C&E Specialist is responsible
for managing relationships with payors and providers to ensure timely credentialing and payor
enrollment of all new and existing providers, group practices and ambulatory surgical centers and
others, as assigned.
Additionally, the C&E Specialist will follow-up on open applications with providers or payors,
including escalation to the appropriate stakeholders to ensure any issues are resolved. The C&E
Specialist will be responsible for all aspects of the credentialing and re-credentialing processes for all
licensed providers who provide patient care at the organization’s clinics, practices, and ambulatory
surgery centers. The C&E Specialist is responsible for ensuring providers are credentialed, appointed,
and enrolled with health plans and privileged at applicable hospitals and patient care facilities.
Duties and Responsibilities:
Maintains up-to-date data for each provider in credentialing databases and online systems; ensures timely renewal of licenses and certifications.
Provide participation with contracted payors by taking appropriate next actions to complete enrollment, such as completing applications, rosters and notifications.
Monitors and actively works towards reduction of Inventory
Escalate items to appropriate stakeholders as needed
Completes monthly expense reports for license renewals, fees, dues, etc.
Obtains up-to-date copies of provider credentials, including, current state licenses, DEA registrations, malpractice coverage and any other required credentialing documents for all providers.
Initiate and maintain Medicare enrollment for practitioners
Tracks and maintains new providers demographic and practice information in all appropriate systems used in the department and submits to appropriate health plans
Maintains working knowledge of workflow, systems and tools used in the department as well as current health plan and agency requirements for credentialing providers
Utilizes department processes and software as assigned to complete credentialing functions, including set up and maintenance of provider information in online credentialing databases and system.
Tracks and renews license and certifications for all providers as directed by leadership.
Ensures practice addresses are current with health plans, agencies and other entities. Duplicate
Works directly with providers to obtain credentialing documents and complete initial and recredentialing with all assigned third-party payers
Processes applications for appointment and reappointment of privileges for providers.
Completes Primary Source Verifications for Credentialing Committee review and delegated enrollment
Works cooperatively with other corporate and practice USDP personnel to resolve any credentialing or contracting question – or escalates to the appropriate stake holder.
Verify any flagged alerts in credentialing software as needed
Work with USDP Medical Malpractice broker to obtain proof of current policy for practitioners.
Audits health plan directories for current and accurate provider information.
Follow up on all emails, calls, inquiries, as needed
Follow-up, research, and resolve provider enrollment application questions or issues as needed
Maintain and distribute delegated roster to appropriate third-party payers.
Completes additional ad hoc projects and reports, as assigned
Notify applicable health plans of provider terminations.
Adheres to all deadlines and schedules
Provides weekly summary of work activities
See/ensure practitioner and/or health plans requests through to completion
Adheres to all safety policies and procedures in performing job duties and responsibilities while supporting a culture of high quality and great customer service.
Performs other duties that may be necessary or in the best interest of the organization.
QualificationsExperience Requirements:
Three (3) - Five (5) years supporting a credentialing and/or enrollment function at either health plan or provider organizations.
Knowledge, Skills and Abilities Requirements:
Must possess strong understanding of the local health care environment, including, but not limited to, managed care policies and procedures, reimbursements mechanisms, and practice management/medical office procedures.
Detail oriented, professional attitude, reliable
Management and organizational skills to support the leadership of this function
Ability to follow or provide verbal & written instructions with sufficient grammar and spelling skills to avoid mistakes or misinterpretations
Interpersonal skills to support customer service, functional, and teammate support needs
Able to communicate effectively in English, both verbally and in writing
Must foster and maintain a cooperative and positive work environment per the Customer Service Pledge
Mathematical and/or analytical ability for intermediate problem solving
Intermediate computer operation:
Proficiency with Microsoft Word, Outlook and especially Excel
Specialty knowledge of systems relating to job function
Knowledge of state and federal regulations for this position; general understanding of HIPAA PII and Confidentiality guidelines.
Supervisory Responsibilities:
This position has no supervisory responsibilities.
