As a member of the Health Care team, this role is accountable for end-to-end management and completion of hospital credentialing and recredentialing applications and completion of provider enrollment and issue resolution to ensure all providers and locations of assigned clients get enrolled in the appropriate commercial, state, and federal health plans.
A significant scope of this role is responsible to foster positive relationships with clients and oversee the day-to-day relations with clients, their personnel and providers. This individual’s daily functions include working independently with clients, their personnel, providers, health plans, and hospital leaders effectively to accomplish the various elements to ensure timely and accurate completion of their assigned tasks. The CRC must deliver exceptional client service, which is an expectation representing Anders vision, mission and core values.
Credentialing, Recredentialing Applications and Payer Enrollment (65%)
- Establish and maintain professional relationships with Client’s offices to ensure proper handling of required information and documentation to ensure a timely outcome of all areas of requested statement of work
- Carry out various credentialing processes in relation to physicians, allied health providers, and various other professionals
- Create client’s data and information in software system
- Responsible for completing applications and issue-resolution on behalf of providers, including communicating with payers to ensure timely application approval
- Process enrollment requests/submissions to all applicable commercial, state and federal health plans (either through the health plans designated process or through our partnered US CVO delegated processes) – For both initial enrollments and reappointments
- For select providers, process applications and reappointments for facility privileges
- Communicate provider enrollment status verbally or by using the Client portal
- Communication liaison between Client, provider and all applicable health plans, including any and all practice status changes and demographic information that may require updates
- Provide thorough and regular follow up client’s office and designated point of contact to ensure proper handling/processing of all applicable applications and supporting documentation
- Adhere to internal policies regarding comprehensive follow up guidelines established for communication with health plans where enrollments have been submitted on a provider’s behalf
- Create and maintain CAQH provider profiles for new and existing providers on an ongoing basis. Review profiles for errors and correct accordingly
- Utilize advance problem-solving skills to resolve issues and conflicts that may arise
- If Applicable, create and update, PECOS and State Medicaid portals (both group level and provider level)
- Conduct follow-ups with health plan credentialing and provider relation representatives on credentialing, re-credentialing and demographic updates for non-delegated plans
- Liaison between provider and health plan when provider is seeking a new contractual arrangement. CRCs are not to engage in contract review and negotiations, this is the sole responsibility of the client
- Maintain all provider data in the organization’s software system.
- Provide periodic provider rosters to health plans and other organizations as required by contractual relationships.
- Maintain an in-depth working knowledge of the requirements established by health plans and provide updates of any significant changes to those providers affected
- Identify issues that require additional investigation and evaluation, validate discrepancies and complete appropriate follow up
- Maintain demographic updates required for compliance with CMS quarterly updates.
- Maintain consistent contact with providers and/or practice directors to ensure expectations are clear and requirements are completed in a timely manner
- Complete special projects within time frames provided by management
- Investigating and vetting all new health plan network offerings and making provider and/or provider’s staff aware of new opportunities either through direct plan offerings or through the CVO’s messenger model
- Assist in maintenance of licensure when notified by state board of need for renewal
Note: External CRCs have direct client relations assigned, Internal CRC’s have no direct client assignments, however, are available to assist clients as needed. Depending on your individual role task will be assigned accordingly.
Management of Ongoing Maintenance (30%)
- Provides ongoing maintenance of clients existing providers on a regular basis
- Maintain and update CAQH with provider information and documents; Re-attest to CAQH in accordance to NCQA standards. (at least once every 120 days)
- Ensures timely completion of client and provider renewals required by all payers. Documents date renewal initiated and completed in health care software system [This is required to track that client/provider renewals were completed prior to their expiration. This process is necessary to meet employee and department goals]
- Ensures timely completion of client and provider Medicare-Medicaid re-validations prior to the expiration date. [This is required to track that client/provider renewals were completed prior to their expiration. This process is necessary to meet employee and department goals]
- Generates monthly client/provider expiration reports and communicates effectively with client/providers to ensure timely receipt of expiring documents, e.g. licenses, CDS, BNDD, DEA, Boards, Malpractice Insurance, etc.
- Accountable for terming providers or locations with payers upon client request in a timely manner not to exceed 30 days from receipt of client’s notice
- Ensures timely completion and submission of providers recredentialing applications for hospital privileges
- Collaborates with client and health plans related to non-network rejected or denied claims
- Coordinates and participates in monthly conference calls with clients regarding providers and payers
- Prepares meeting agendas and takes minutes as a method of communication of next steps to clients/providers and the Anders Health Services team
- Participates in education and training events to enhance provider enrollment and payer credentialing knowledge
- Attends Health Services staff meetings, ancillary and firm meetings
General Responsibilities (2%)
- Documents billable time appropriately in Anders CCH Axcess
- Notifies supervisor of potential concerns outside of employee’s scope of responsibility
- Notifies supervisor of client request for Statement of Work outside the scope of their current engagement