The Provider Enrollment Coordinator II is responsible for ensuring that credentialing activities comply with URAC, NCQA, state and federal regulations.
Essential Functions:
Ensure credentialing activities comply with URAC, NCQA, state and federal regulations
Check daily work queues to determine priority of workload including routine credentialing processing and maintenance
Perform review functions on files prior to initiating Primary Source Verification (PSV) and Secondary Source Verification (SSV) including, but not limited to discontinuations, provider notifications, and other credentialing functions
Coordinate efforts with Provider Relations (PR), Provider Data Integrity and provider to complete/obtain all missing components of each application
Complete PSV and SSV for providers and organizations
Utilize critical thinking skills when reviewing provider files to determine if provider meets established criteria
Submit completed applications for auditing prior to Credentialing Committee
Responsible for staying abreast of: state and federal regulations pertaining to provider credentialing and re-credentialing, CareSource Credentialing Policies and Procedures and Standard Operating Procedures to ensure that all credentialing and maintenance of providers are managed to expectations, and NCQA and URAC Credentialing Standards to ensure compliance and continued accreditation
Perform monthly mailings for providers due for re-credentialing
Complete provider re-credentialing within required time-frame
Respond to calls and emails from internal/external customers, Monday-Friday, 8am-5pm
Scan credentialing files and attach in Cactus in a timely manner
Assist customers while on the Credentialing phone queue
Adhere to Credentialing Service Level Agreements
Identify and prepare provider issue files to present to Medical Director for review, decision and signature prior to Credentialing Committee presentation
Prepare and reconcile weekly Credentialing Committee Roster and present to Medical Director for review, approval and signature
Process approved weekly Credentialing Committee files utilizing Cactus to generate roster, close records, create appointment letters and update status codes
Work on special projects as assigned that include reconciliation projects, processing urgent provider and organization applications, and others
Maintain confidentiality of provider information and ensure all provider files are securely stored in the credentialing file drawer or in the provider file room at close of business each day
Perform any other job duties as requested
Education and Experience:
High School Diploma or equivalent is required
Minimum of one (1) year credentialing experience/knowledge is required
Competencies, Knowledge and Skills:
Intermediate computer skills and ability to type 60+ WPM
Proficient in Microsoft Word and Excel
Knowledge of URAC and NCQA accreditation credentialing standards
Communication skills
Ability to work independently and within a team environment
Attention to detail
Familiarity of the healthcare field
Knowledge of medical terminology
Knowledge of Medicaid & Medicare managed care
Critical listening and thinking skills
Uses proper grammar
Technical writing skills
Time management skills
Proper phone etiquette
Customer service orientated
Decision making/problem solving skills
Licensure and Certification:
NAMSS certification in credentialing is preferred
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$41,200.00 - $66,000.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1