Credentialing Enrollment Specialist

Overview

Job Summary

The Credentialing Enrollment Specialist is responsible for the timely, accurate, and compliant enrollment of Atrium Health providers with government payers, as well as the timely and accurate processing, follow up, and verification of completion of applications for participation in Medicare (NC/SC), NC Medicaid (NCTracks), SC Medicaid programs for AH providers and physician groups. The position is responsible for ensuring that the credentialing and enrollment functions are complete in compliance with all Atrium Health, CMS, State, and national accrediting agency(s) standards.

Essential Functions

• Independently processes and submits complete, timely and accurate enrollment applications to The Center for Medicare Services (CMS) and state Medicaid offices on behalf of new groups and currently employed Atrium Health Medical Group (AHMG) providers and groups billing under AH MG tax ID numbers.
• Resolves issues and supports Practice Leadership / Practice Manager regarding provider enrollment and credentialing for AHMG, Affiliates and the Professional Billing Office.
• Regularly follows up of status of submitted applications and provider maintenance requests with CMS and state Medicaid offices and communicates status updates to all constituents via tracking system and email.
• Demonstrates the ability to communicate professionally and clearly in both verbal and written form to physicians, corporate staff, external agencies, and government / managed care organizations.
• Accurately and clearly documents process steps, dates, and work status in the system.
• Answers departmental telephone and emails, routes to appropriate staff and takes accurate messages as needed. Commits to return all phone and email inquiries within 24 hours even if not resolved.
• Manages time, prioritizes assignments, and coordinates functions effectively to meet the departmental goals and quality standards.
• Maintains confidentiality of all information related to credentialing and recredentialing.
• Promotes and assists in the smooth, efficient delivery of departmental services to providers, AH MG, AH, and other corporate departments and outside agencies.
• Performs other duties and responsibilities as assigned with minimal supervision and within time limit specified.
• Participates in performance improvement activities.
• Collaborates effectively with all personnel within the department and throughout Atrium Health.
  
• Performs primary source verifications of documentation required for managed care credentialing and re-credentialing of MGD providers.
• Provides issue resolution and support regarding billing issues as they relate to provider enrollment and credentialing for MGD providers and the Central Billing Office.
• Enters provider data in the ECHO database according to established departmental processes and provides feedback to other System entities as to the status of the applicants.
• Performs follow-up on needed information (expired licenses, board certifications insurance and DEA registrations) on an ongoing basis and ensures receipt of same in a timely manner.
• Prepares physician files for file audits by managed care organizations, Corporate Compliance and accreditation entities.
• Conducts practice site visits for practices within MGD. Facilitates communication tools and or activities to maintain timely and accurate flow of information to Managed Care Organizations (MCOs) and the System.
• Reviews hard copy and electronic provider directories and other information produced by managed care organizations reflecting MGD and the System's demographics and participation.
• Provides Team member support to the CPN Credentialing and Quality Review Committee.

Physical Requirements

Perform most duties under normal office conditions which may include sitting for long periods of time, standing, walking, using repetitive wrist/arm motion or lifting articles 20-50 pounds. Work is subject to time sensitivity, heavy volumes, and frequent interruptions, either by phone or other employees. Must use frequent and variable body movements during filing and maintaining records. Require frequent verbal and written communication in English to employees, corporate staff, providers, and external agencies. Require occasional travel to other corporate offices. Use of personal vehicle required. Intact sense of sight and hearing required.

Education, Experience and Certifications

High school diploma or GED required; Bachelor's degree preferred. Three years' experience in a role that performs or supports provider credentialing, privileging, and/or enrollment in either a hospital, managed care plan or CMS environment is required. Knowledge of and experience with personal computers, Windows and Microsoft applications, copier and fax machines and multi-line telephone required. Experience in typing, word processing, and business correspondence is required. Certification through National Association of Medical Staff Services (NAMSS) as Certified Provider Credential Specialist (CPCS) or Professional Medical Services Management (CPMSM) preferred.