SCOPE / GENERAL PURPOSE OF JOB:
Responsible for fundamental concepts, practices and procedures in negotiation and contractual provisions of managed care, commercial and government payor contracts; to include preparing, timely completion and submittal to Contracting/Credentialing Manager and provider/client for final approval prior to execution. Responsible for rate methodologies and payer fee analyses preparation for client database entry to insure correct payor reimbursement per contract rates. Responsible for forwarding in a timely manner, all payor credentialing and re-credentialing of health care providers with applicable payor and hospital privilege applications to Credentialing Specialist(s). Understanding that timely credentialing, re-credentialing and effective contracting will allow appropriate revenue generation and claims submission requirements to facilitate billing. Closely works with facilities, providers and their staff, state and federal licensing agencies and insurance carriers in relationship to credentialing and contracting processes. Builds and maintains professional relationships with RCI Billing staff, payor provider representatives and clients/providers to insure a high level of customer service and satisfaction. Entry –level professional with limited or no prior experience; learns to use professional concepts to resolve problems of limited scope and complexity; works on developmental assignments that are initially routine in nature, requiring limited judgment and decision making. Works under immediate supervision, performing assigned tasks where instructions are usually detailed in nature.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Basic (entry-level) understanding of payer contracting to include request process, review and contract analyzes in Government, Managed Care and Commercial payor contracts on behalf of the client/provider.
- Under supervision, negotiates payer contracts and rates in a timely manner to insure appropriate contract language such as timely filing, clean claims, length of term, rates, etc., in contract outcome. Once final negotiation is reached, contract and rate analysis must be approved in writing by Contracting/Credentialing Manager and provider/client prior to execution.
- Completes payer fee analyses as part of the contracting process to submit to RC Billing EDI department for client database entry to insure correct reimbursement.
- Demonstrates excellence in tracking and thoroughly documenting in Wybtrak Note Area and other areas the status follow-up processes of payor contracting for providers/clients for positive outcomes.
- Maintenance and submittal to RC Billing EDI department of any client fee schedule change, annually or otherwise
- Demonstrates understanding and knowledge of Government and Commercial payors’ credentialing processes/requirements.
- Establishes and maintains provider National Provider Identifier (NPI) registration NPPES (National Plan & Provider Enumeration System) information database.
- Completes, submits and confirms any Government payor such as CMS (Centers for Medicare & Medicaid Services) or state Medicaid EFT (electronic funds transfers) that is required in association with enrollment forms, as applicable.
- Contacts providers/clients, provider medical office staff, licensing agencies, payor provider representatives and insurance carriers to complete contracting processes.
- Creates and timely maintains each client’s PAR (Payer Participation List) list on the Shared Drive.
- Maintains working knowledge of provider credentialing and contracting.
- Expands knowledge base by participating in educational opportunities.
- Ensures strong communication with Central Business Office (“CBO”)management team and other staff members.
- Ensures compliance with RC Billing Reimbursement Policies and Procedures to maximize efficiency. Ensures compliance with appropriate industry regulations and State and Federal regulations.
- Maintains and appropriately manages, in electronic format, all payor contracts.
- Demonstrates the use of appropriate and proper grammar, punctuation and spelling and the ability to effectively communicate (both written and verbal) as well as via email with all involved entities within position.
- Manages workload to meet deadlines and maintain department standards on turnaround time to insure timely provider/group/facility payor participation effective dates.
- Ability to work productively and effectively in coordinating, correct and effective decision making and meeting deadlines in a detail-oriented manner working under immediate supervision of Dept. Management Team members.
- Proficiency in Excel and Microsoft Office software, including the ability to create calculation spreadsheets for fee analyses reporting and processing.
- Maintains working knowledge of applicable laws and regulations as they relate to assigned responsibilities.
- Maintains confidentially of all information related to patients, clients, finances and cost effective health care delivery issues.
- Demonstrates the ability to work well with peers while ensuring a strong cohesive team.
- Additional duties as assigned.
EDUCATION AND/OR EXPERIENCE:
- BA or 0-2 years of experience in related area of physician credentialing and/or payer contracting.
- Knowledge of organization policies and procedures.
- Knowledge of health care administration principals.
- Knowledge of basic business office billing policies and procedures.
- Knowledge of payor contracting, credentialing operating procedures and practices.
- Skill in exercising initiative, judgment, discretion and organizational skills to achieve business unit objectives.
- Skill in identifying and resolving problems.
- Ability to communicate effectively and professionally.
- Ability to establish and maintain effective professional working relationships with all employees and clients. Ability to communicate effectively orally and in writing.
- This position relies on limited experience and judgment to plan and accomplish goals.
CERTIFICATIONS / LICENSURES / CREDENTIALS: Certified Professional Credentialing Specialist OR 2 years of credentialing experience with goal to seek CPCS certification within 2 years of employment OR 3 years of credentialing experience in lieu of certification
SUPERVISORY RESPONSIBILITIES: None
The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position requires full range of body motion including manual and finger dexterity and eye-hand coordination. The position additionally requires standing/sitting for extensive periods of time. Occasional lifting and carrying items weighing up to forty (40) pounds may be required. Requires corrected vision and hearing to normal range.
The work environment characteristics described are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment involving frequent interaction with staff, clients and the general public.