GENERAL SUMMARY:
Under general supervision, performs provider enrollment and compliance functions
within a Clinically Integrated Network (Network). Key duties include data management,
ensuring providers meet standards and regulations, processing Network credentialing
applications, maintaining relationships between payors, clinics, and providers, and
verifying compliance with contractual obligations. The role performs further credentialing
functions including resolving claims issues, assisting with onboarding new practices,
and conducting audits to ensure compliance. Responsible for creating communication
materials, maintaining up-to-date payor information, and providing patient support for
Medicaid redetermination and enrollment.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
- Ensures providers are enrolled in the Network according to current standards and
regulations and maintains stringent compliance with payors.
- Facilitates preparation for the Network Credentialing Committee, reviewing files for
accuracy and completion. Works with the Committee Chair to perform the
administrative review process and attain approval sign-off.
- Responsible for meeting any contractual obligations outlined within all delegated
credentialing agreements held by the Network.
- Serves as the point of contact for Network practices to address claims issues with
Network payors by troubleshooting on behalf of the practice and working with the
payor to resolve.
Provides enrollment assistance/support to Network provider members for nondelegated health plans as needed.
Supports new practice onboarding by providing support pertaining to credentialing,
execution of participation agreements, health plan enrollment, fee schedules, and
ensure smooth transition of support to Network practice transformation team.
- Performs data entry, collection, and analysis to complete tasks supporting provider
primary source verifications and enrollment processes.
- Responsible for completing various audit activities to ensure contractual compliance
and satisfying NCQA standards. Audit activities include annual audits which are
initiated by delegated payors, regular auditing of primary source verifications (PSV),
and conducting annual audits of sub-delegate groups to the Network, such as the
Henry Ford Health Central Verification Office.
- Ensures Network practice compliance and contractual obligations through
comprehensive and manual validation of information (i.e., confirmation of practice
hours). Performs tasks to support accurate records and roster management
including:
a. Network provider membership profiles within Network's data management tool.
b. Updates external provider alignment tools used to align physicians to a particular
group for purposes of their quality rewards program.
c. Maintains accurate record of specialist referral information, provider panel status
by product line, and Network's criteria for incentive eligibility.
d. Supports Network patient alignment including but not limited to member transfer
submissions and resolution tracking.
e. Responsible for accurate and prompt submission of the Network provider roster
to each payor using payor-specific formatting. Additional ad-hoc requests require
creation of provider rosters, using variety of data platforms, for multiple usecases.
f. Maintains the Network provider roster for the Accountable Care Organization
(ACO) contract including all provider additions, terminations, or changes to the
ACO contract.
g. Maintains current payor information, including fee schedules and policies, within
the Network's SharePoint website.
h. Through ongoing partnerships and collaboration with non-delegated health plans,
ensures all appropriate providers are accurately aligned to Network.
10.Performs outreach to patients due for Medicaid redetermination, provides education
to patients on process, answers questions, assists with online forms, and provides
enrollment support.
11.Follows the procedures defined by Network's patient compliant policy including
reviewing patient concerns with Network administrative leadership and Network
medical directors.
12.Supports the Network communications and education through creating a monthly
payor newsletter capturing updates from Network contracted health plans including
coding, billing, prior authorizations, upcoming webinars, operations, and provides
CPT coding and billing education to Network members.
13.Performs ongoing evaluation, maintenance, and execution of the Network
participation agreements. Maintains all policies and procedures related to Network
provider affairs and delegated credentialing.
14.Additional responsibilities including, but not limited to:
a. Maintenance of the Network Behavioral Health Provider Directory.
b. Attending the Network Credentialing Committee as requested by leadership.
c. Submission of Blue Care Network's Medical Care Group affiliation form for
Network independent providers.
d. Payor outreach as needed on behalf of providers.
EDUCATION/EXPERIENCE REQUIRED:
High school diploma. Associate degree preferred.
Two (2) years of provider enrollment, provider billing, or credentialing experience.
Demonstrated knowledge of all aspects of the insurance provider enrollment
process.
- Ability to work independently, in a demanding environment, managing deadlines and
competing priorities without compromising quality or accuracy.
- Meticulous, highly organized with strong business acumen, quantitative and
analytical skills.
Excellent verbal and written communication skills.
Comfortable and competent interpreting information and making decisions.
Demonstrated ability to interact professionally with all levels of business and clinical
organizations.
Proficient in Microsoft suite of tools including Outlook, Word, and Excel.
Proficiency in relevant applications including EPIC, Morrisey, and/or MDStaff
preferred.
CERTIFICATIONS/LICENSURES REQUIRED:
Certified Professional Coder (CPC) preferred.
Must meet or exceed core customer service responsibilities, standards and behaviors as
outlined in the Henry Ford Health Customer Service Policy and summarized below:
? Communication ? Ownership
? Understanding ? Motivation
? Sensitivity ? Excellence
? Teamwork ? Respect
Must practice the customer skills as provided through on-going training and in-services.
Must possess the following personal qualities:
? Be self-directed.
? Be flexible and committed to the team concept.
? Demonstrate teamwork, initiative, and willingness to learn.
Additional Information
Organization: Corporate Services
Department: HF CIN
Shift: Day Job
Union Code: Not Applicable
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Partnering with nearly 2 million people on their health journey, Henry Ford Health provides a full continuum of services at 250 care locations throughout southeast and south central Michigan. With 33,000 valued team members, Henry Ford is also among Michigan's largest and most diverse employers. Our superior care and discoveries are powered by nearly 6,000 physicians, researchers and advanced practice providers. Learn more athenryford.com.
Benefits
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