Position: Credentialing Specialist

Subtype: (Payor Enrollment)

Monogram Health is seeking an individual who has worked at either a large clinical organization/provider group, medical staff office, third party payor enrollment organization or credentials verification organization. The credentialing specialist contributes to the ongoing advancement of the organization’s goals by ensuring practitioners are credentialed, contracted, and loaded as in-network participating practitioners in a timely and efficient manner. The department’s mission is to implement industry best practices to reduce processing timeframe with direct and delegated payors to jumpstart the revenue cycle reimbursement process and allow Monogram Health to schedule patients with practitioners as early as possible. The credentialing specialist is responsible for managing payor enrollment of federal, state and commercial health plans. The credentialing specialist will identify correct processing protocol and requirements for each contracted payor. The credentialing specialist will obtain required information and documents from practitioner, complete submission of applications and follow-up with health plans until the practitioner is fully credentialed and enrolled.

The credentialing specialist identifies, analyzes, and resolves information discrepancies, and time gaps that could adversely affect our organization’s ability to credential, enroll and/or privilege providers. The credentialing specialist is responsible for maintaining timely, accurate and comprehensive data in credentialing software and shared drives which can be subject to internal, health plan and NCQA audits at any time.

The credentialing specialist must have overall knowledge of external payor credentialing, enrollment, and networking process for fee-for-service and value-based agreements. The role will require knowledge of enrolling physicians, midlevel and allied health practitioners in all states and become familiar with payor specific telehealth requirements.

Prior to coming to Monogram Health ideal candidates may have had roles such as: Provider Enrollment Specialist, PES Account Manager, PES Team Lead, Credentialing Specialist, Credentialing Team Lead, Medical Staff Office Professional

Possessing these traits may indicate high compatibility for role: Persistent, detailed and process oriented, affinity for accuracy, deadline conscientious, excellent documentation skills, adaptable, strategic and organized

Roles and Responsibilities

• Ability to interact positively in a team environment, demonstrating superior teamwork skills
• Coordinate with onboarding credentialing specialist for seamless transition to payor enrollment within required timeframes
• Responsible for initial individual and group enrollment as well as demographic updates. Will also submit enrollment requests associated with new payor contracts due to company growth.
• Follow-up timely until credentialing, contracting and networking approval confirmed by the payor
• Informs management regarding the status of departmental operations and provider credentialing, enrollment or contracting issues of concern.
• Produce and submit delegated rosters to contracted clients
• Research payer requirements to gather all details to appropriately enroll practitioner
• Communicate and advise management/billing/Client Partnership of the paperwork/items necessary to begin enrollment process for new onboarding clinicians as well as existing clients
• Follow Licensing and Credentialing Escalation Pathway for practitioners or applications with outstanding items/information needed to finalize the enrollment process
• Generate and send appropriate payor enrollment forms/correspondence to practitioners
• Communicate clearly with practitioners, healthcare leadership and administrative staff as needed to provide timely responses upon request on day-to-day credentialing issues as they arise
• Send secure credentialing/enrollment documents for electronic signature via Adobe Docusign or similar platform
• Obtain all required signatures and documents needed to submit a clean application to the payor
• Key practitioner demographics and enrollment data into credentialing software
• Scan all related enrollment documents and applications into credentialing software
• Review, submit and follow-up on internal credentialing applications for healthcare providers, ensuring accuracy and completeness of information.
• Develops and maintains strong relationships with practitioners and payor contacts to facilitate timely payor enrollment
• Serve as a primary point of contact for payor enrollment follow-up with payors
• Contact payors to request provider enrollment application packages and/or required action for enrollment and continue follow-up with payors by telephone or email until all provider numbers and network effective dates are issued and confirmed.
• Understands the importance of organized documentation and timely follow-up
• Prepare and distribute weekly status reports to execute leadership team
• Document and note all critical payor enrollment lifecycle events in credentialing software (ie. Enrollment Documents Received from Practitioner, Application Received by Payor, Requests for Information, Committee Review and Network Approval)
• Maintain data in credentialing software as specified in policy and procedure
• Maintain detailed and up-to-date provider credentialing records in compliance with regulatory standards.
• Updoad and store all submitted application in credentialing database
• Initiate and maintain standard industry credentialing databases/portals on behalf of practitioner and MH provider groups. This includes but is not limited to CAQH; ProviderSource, Availity, CMS I&A, NPPES, PECOS, State Medicaid portal
• Communicate effectively with Licensing, Credentialing, Operations, Clinical, Billing and Client Partnership teams
• Collaborate with internal stakeholders, such as contracting and billing departments, to facilitate provider enrollment and contracting processes.
• Able to coordinate and present payor enrollment updates and escalations to management and Client Partnership team.
• Verbal and communication skills are essential tools to resolve practitioner and payor issues
• Provide ad-hoc reporting and special projects when requested
• Familiar with Medicare Advantage credentialing and telehealth payor requirements
• Maintain confidentiality of information and security of credentialing and payor enrollment files.
• Able to take advantage of department training/resources for self-guided learning
• Willingness to be cross trained in primary source verifications, medical licensing and hospital privileging as additional coverage support needs arise.
• Other duties as assigned

Position Requirements

• Bachelor's Degree preferred
• 3-5 years’ experience required
• Proficiency in Microsoft office applications (e.g. Word, Excel, PowerPoint) and Smartsheet
• Expertise in Medicaid, Medicare and commercial payor credentialing requirements.
• Must possess excellent verbal and written communication skills
• Excellent attention to detail
• Ability to research data and draw conclusions
• Must be able to work in a self-directive manner and manage multiple simultaneous time-sensitive deliverables.
• Ability to manage assigned projects individually, without supervision, and make independent decisions
• Consistently demonstrates flexibility, a payor focus, terrific organizational skills and a passion for details
• Consistently meets project deadlines and communicates and projected delays with manager/director in advance of deadlines to ensure business needs are met
• Proficient with credentialing systems and learns new systems/processes quickly

Benefits

• Comprehensive medical, dental, vision and life insurance
• Flexible paid leave and vacation policy
• 401(k) plan with matching contributions

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.