About This Role
This role involves overseeing the credentialing and re-credentialing processes for healthcare providers, ensuring compliance with all relevant regulations and standards. It suits a highly motivated and detail-oriented professional who can maintain the integrity of provider information, facilitate smooth medical payer enrollment, and uphold the organization’s commitment to healthcare compliance and accreditation standards. This position offers an exciting opportunity to contribute to a dynamic healthcare environment where accuracy, efficiency, and regulatory knowledge are essential for success.
Responsibilities
- Review and verify medical credentialing applications, ensuring completeness and accuracy in accordance with healthcare industry standards
- Manage provider enrollment with various health insurance payers, including Medicare, Medicaid, and commercial insurers, ensuring timely submissions and follow-up
- Maintain up-to-date knowledge of CMS (Centers for Medicare and Medicaid Services) regulations, state healthcare laws, and accreditation standards such as JCAHO and NCQA
- Utilize healthcare software applications and databases to track credentialing status, update provider records, and generate reports for internal review
- Coordinate with healthcare providers to gather necessary documentation while handling confidential information with utmost discretion
- Ensure compliance with healthcare policies related to managed care organizations (MCOs), health regulation policies, and healthcare accreditation standards
- Collaborate with contract management teams to review provider agreements and ensure adherence to regulatory requirements
Requirements
- Strong understanding of managed care processes, health insurance policies, and payer enrollment procedures
- Proven experience in medical credentialing application review and healthcare software applications
- Familiarity with CMS regulatory compliance, NCQA standards, JCAHO accreditation requirements, and state healthcare regulations
- Excellent knowledge of medical terminology, database management experience, and healthcare compliance protocols
- Proficiency in Google Workspace for documentation and reporting purposes
- Ability to handle confidential information professionally while maintaining attention to detail under tight deadlines
- Effective communication skills to liaise with providers, payers, regulatory agencies, and internal teams