Lone Star Circle of Care

  • Payer Enrollment Specialist (Georgetown)

    Job Locations US-TX-Georgetown
    Posted Date 2 weeks ago(7/2/2018 6:02 PM)
    # of Openings
    1
    Category
    Administrative/Corporate Support
  • Overview

    Ensures practitioners are enrolled and credentialed with all active system-wide payers and assists with site credentialing.

    Responsibilities

    Payer Credentialing:

     

    • Facilitate completion and submission of initial payer credentialing applications upon hiring of practitioners.
    • Regularly follow up on payer credentialing applications submitted that are pending.
    • Manage the ongoing re-credentialing process with payers.
    • Create and maintain a payer credentialing file for each practitioner. Practitioner information contained in this file is considered confidential and should be handled as such.
    • Maintain Practitioner’s CAQH profile by entering data, supporting documents, and re-attesting quarterly.
    • Maintain knowledge of current eligibility requirements, forms and documentation required by each payer in order to add and maintain LSCC practitioner participation with each payer.
    • Establish and maintain an effective professional relationship with the credentialing and provider relations staff of each payer.
    • Provide -monthly, quarterly, and/or annual reports to payers upon request, and in accordance with delegated credentialing agreements.
    • Assist with pre-delegation and annual payer audits in accordance with delegated credentialing agreements.
    • Respond in a timely manner to request from payers and various LSCC departments to answer any payer credentialing-related questions and work to solve credentialing-related issues.
    • regularly communicate with appropriate administrative staff regarding practitioners’ standing with payers.
    • Maintain a close working relationship with the LSCC billing department to facilitate the rapid resolution of credentialing-related issues.
    • Provide support as needed in all aspects of the credentialing process for LSCC.

     

    Site Credentialing (Assist):

     

    • Ensure all new clinic sites are appropriately assigned a site NPI number, medicaid TPI number, and Medicare PTAN number following FQHC or Fee for Service (FFS) guidelines.
    • Add new practice locations to existing Medicare Part B Groups and creating new Medicare Part B Groups for new FFS clinic sites as they are established.
    • Ensure that all contracted payers (Medicaid MCOs and commercial payers) credential new clinic sites as they are established.
    • Complete Medicare and Medicaid revalidation applications in a timely manner to ensure all certifications are kept active and in good standing with CMS.
    • Maintain knowledge of all FQHC and FFS requirements for certifying with Medicare and Medicaid.
    • Remain in constant communication with LSCC billing leadership to ensure claims are released when appropriate to minimize loss of revenue.

    Qualifications

    REQUIRED EXPERIENCE, EDUCATION, AND LICENSE:

     

    • Minimum of a high school diploma or GED
    • Minimum of two (2) + years’ credentialing experience in compliance with JCAHO, NCQA and URAC standards

     

    PREFERRED EXPERIENCE, EDUCATION, AND LICENSE:

    • Proficiency with MS Office Suite (Word, Excel, and Outlook)
    • CAQH Experience
    • Bilingual English/Spanish language skills are a definite plus

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