Senior Credentialing Specialist, TPR
Tenet Healthcare Corporation
Deliverables include:
- Work closely with the local market onboarding team on all new providers in the pipeline.
- Requests all credentialing data and supporting documents from the physician. Communicates to market onboarding team when delays with the physician are in jeopardy of interrupting the defined project timelines.
- Candidates should have knowledge of NCQA standards, delegated credentialing, and Primary Source Verification.
- Prepare and/or update the provider’s CAQH application for newly affiliated and existing healthcare providers.
- Ability to build and maintain peer-to-peer relationships with all relevant market Health Plans. Strategically communicate newly affiliated providers to plan to initiate TIN change/demographic flip or initiate credentialing.
- Establish credentialed status to facilitate billing.
- Maintains credentialing databases and ensures up-to-date tracking of file process.
- Display in-depth knowledge of and execute all standard operating procedures (SOPs) as well as communicating issues, trends, and concerns to Regional Supervisor.
- In-depth working knowledge of the various applications associated with all plans and the workflow process. Identify any opportunity for process improvement and work with Regional Supervisor to challenge payors agendas.
- Ensure all workflow items are completed within the set turn-around-time, meeting quality expectations.
- Issue resolution relating to billing and collecting for services rendered. Educating internal markets on contractual obligations for each payor surrounding managing authorizations, billing requirements and operationalizing language to ensure that we are able to bill and collect for services rendered.
- Provide credentialing information to Market Operations to ensure that they have the information needed to effectively manage the practices from a credentialing perspective.
- Data Entry- 5%
- Initial credentialing or recredentialing per NCQA- 30%
- Health plan submission (delegated, non-delegated)- 30%
- UCC credentialing- 25%
- Other duties as assigned- 10%
Qualifications:
- Minimum of five years of experience in a managed care role, centralized credentialing office or related health care environment, such as credentialing or file maintenance.
- Knowledge of health plan and governmental payer credentialing, enrollment, and requirements.
- Knowledge of CAQH application.
- Knowledge of contract language interpretation and administration
- Ability to work within a deadline-intense environment.
- Demonstrated problem-solving and customer service skills.
- Knowledge of Microsoft Word and other PC applications.
- High School Diploma required; completion of an applicable Vocational or Technical training program preferred.
- Excellent verbal and written communication skills.