· Successfully supports the full scale of the data collection and verification processes for the medical staff services and payer enrollment processes.

· Compile, evaluate, and present provider-specific information for use by Medical Staff Services and in the Payer Enrollment process.

· Conducts primary source verification of initial and reappointment applications in accordance with Accreditation, Regulatory, and Medical Staff Bylaws. Obtains provider sanctions, complaints and adverse data.

· Communicates with Providers via e-mail, phone, written, and face-to-face to gather all signatures and information necessary to complete the collection of data for new providers and updates to existing provider profiles.

· Coordinates the sharing of payer enrollment data needed for enrollment, contracting, and other related purposes with Providers, Medical Staff Services, Managers/Supervisors, Insurance Payers/Networks, etc.

· Data collected includes but is not limited to the collection of educational certifications of all degrees, Drug Enforcement Administration (DEA) number, State License number, Board Certification, CV, Malpractice Insurance, and state insurance.

· Maintains and manages data input and data integrity for the MD Staff electronic credentialing data management program.

· Processes requests related to physician maintenance in hospital and clinic HIS systems and communicates additions or changes to the appropriate parties.

· Oversees provider enrollment software upgrades and any on-going changes with software applications.

· Keeps current with insurance plan requirements for plan compliance and successfully implements changes.

· Reviews State Report for corrections that may be necessary to Provider Maintenance.

· Maintains provider payer enrollment files in the MD Staff or other approved system.

· Maintains an accurate Physician Provider grid for all participating plans for the facility and clinics and communicates the grid to stakeholders on a regular basis.

· Maintains accurate provider membership directory with each network to ensure that all employed physicians are properly loaded in the vendor listing as contracted provider.

· Updates Facility payer enrollment with all payers.

· Works with Billing and Collection teams to ensure providers are credentialed and loaded in payer systems appropriately to prevent payer enrollment denials.

· Completes New Provider packets within 10 days of provider employment, whenever possible notifying all plans via application for enrollment to ensure timely network affiliation and effective dates with all plans.

· Updates provider attestation for CAQH for all practitioners every 120 days as permitted by provider.

· Follows up within established timeframes with Insurance Carriers or Networks regarding documentation submitted.

· Provides immediate updates to Business Office staff of finalized credentials.

· Monitors and advises physicians on upcoming license expirations. 

· Notifies plans when physicians are termed or leave our employment or affiliation within established timeframe for payer.

· Monitor department email for incoming credentialing requests, data entry updates, and changes for all provider types and terminations. Respond and communicate to providers and staff timely.

· Manage and maintain provider rosters (both via email and online) on a quarterly basis.

· Coordinate with third party vendors to obtain provider signatures and documentation for out of state Medicaid.

· Utilize and navigate governmental and non-governmental websites.

· Participate in the development of internal credentialing and enrollment processes.

· Maintains checklists and application mapping in MD Staff to improve process flow.

Education: High school diploma or equivalent

Experience: At least one year experience in payer enrollment of physicians and other professional practitioners OR two or more years’ experience with medical billing and/or collections OR at least one year experience in medical office staffing OR two or more years of administrative support experience.

Skills and Knowledge: Proficient in Microsoft Office

Education: College degree

Experience: One or more years’ experience in payer enrollment preferred.