Provider Enrollment Coordinator II

Employer: CareSource

Job Summary:

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

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