Provider Enrollment Credentialing Specialist Virtual in Brentwood, TN at Parallon

Date Posted: 7/10/2018

Job Snapshot

Job Description

Parallon believes that organizations that continuously learn and improve will thrive. That's why, after more than a decade, Parallon remains dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. 

As one of the healthcare industry's leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized services in the areas of revenue cycle, purchasing, supply chain, technology, workforce management and consulting. 

Parallon's purpose is simple. We serve and enable those who care for and improve human life in their communities.  




Provider Enrollment Credentialing Specialist




Job Summary – The Provider Enrollment Credentialing Specialist is responsible for processing credentialing files and enrollments for new and existing individual providers and group practices, such as initiating new enrollments with Commercial and Governmental payors and reporting demographic or other provider changes. Other duties include follow-up on open applications with providers or payors, including escalation to the Provider Enrollment Account Management team or Strategic Pricing and Analytics (SPA) Managed Care Team for resolution.

Supervisor – Provider Enrollment Manager

Supervises – None

Duties (included but not limited to)
  • Ensure provider participation with contracted payors by taking appropriate next actions to complete enrollment, such as completing applications, rosters, and notifications
  • Work with payors and providers to ensure compliance with enrollment process
  • Initiate contact with payors and practices via telephone or electronic methods with respect to provider enrollment and billing errors, utilizing proper customer service protocol
  • Prepare credentialing files for presentation to the Credentialing Committee or the Chief Medical Officer (CMO)
  • Confirm completeness and accuracy of credentialing files prior to committee presentation
  • Work closely with Provider Enrollment Manager to resolve credentialing file issues
  • Ensure payor requirements for submission of rosters are met
  • Monitor inventory, including provisional, credentialing, and recredentialing for all providers as well as expirables to meet payor requirements
  • Assist during payor-delegated credentialing audits
  • Escalate items to other areas outside of department as needed
  • Update and maintain data in appropriate Provider Enrollment systems while ensuring accuracy and data integrity
  • Review correspondence received and perform appropriate action to resolve
  • Appropriately resolve or escalate payor application denials
  • Meet and maintain established departmental performance metrics for production and quality
  • Maintain working knowledge of workflow, systems, and tools used in the department
  • Maintain working knowledge of National Committee for Quality Assurance (NCQA) guidelines and state requirements
  • Adhere to established credentialing policy guidelines and procedures
  • Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
  • Other duties as assigned

Knowledge, Skills, and Abilities
  • Organization - proactively prioritizes needs and effectively manages resources
  • Communication - communicates clearly and concisely, verbally and in writing, utilizing proper punctuation and correct spelling
  • Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
  • Interpersonal skills - able to work effectively with other employees, patients, and external parties
  • Leadership - guides individuals and groups toward desired outcomes, setting high performance standards and delivering leading quality services
  • Tactical execution - oversees the development, deployment, and direction of complex programs and processes
  • PC skills - demonstrates proficiency in Microsoft Office applications and others as required
  • Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures, and systems
  • Basic skills - demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes; able to work quickly and accurately in a fast-paced environment while managing multiple demands; able to work both independently and collaboratively as a team player; demonstrates adaptability, analytical and problem solving skills, and attention to detail; and able to perform basic mathematical calculations, balance and reconcile figures, and transcribe accurately

Education
High school diploma or GED required

Experience
Minimum one year related healthcare experience preferred, such as Medicare/Medicaid Enrollment or Managed Care Enrollment. Relevant education may substitute experience requirement. Knowledge of provider credentialing and primary source verification, National Committee for Quality Assurance (NCQA) policies and procedures, state specific certificate and licensure requirements and site visit requirements, National Plan and Provider Enumeration System (NPPES) and Council for Affordable Quality Healthcare (CAQH) preferred. Minimum of two years of credentialing experience highly preferred. 

Certificate/License
Certified Provider Credentialing Specialist (CPCS) preferred. 

Physical Demands / Working Conditions– Requires prolonged sitting/standing, some bending, stooping, walking and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports or other information. Requires lifting papers/boxes and pushing/pulling up to 25 pounds occasionally. Work is performed in an office environment or hospital setting. Work may be stressful at times. Contact may involve dealing with angry or upset people. Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.

OSHA Category– The normal work routine involves no exposure to blood, body fluids, or tissues (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency care or first aid, or to be potentially exposed in some other way.