Credentialing Coordinator, MercyCare Insurance

Overview

• Credentialing Coordinator, MercyCare Insurance, Days, 80 Hrs / 2 wks
• Location: MercyCare Bldg; Janesville, WI. Hybrid and/or remote schedule avaliable. Mercyhealth does not currently support remote workers with residency in the following states: CA, OH, OR, PA, NJ, NY.

Performs duties related to MercyCare Health Plans (MercyCare) functions, which include but are not limited to credentialing new and established healthcare providers, maintaining information which includes primary source verification, follow-up, data collection, data entry, and document review. The Lead Credentialing Coordinator will manage the monthly credentialing committee working closely with the Medical Director to review files for the committee., Responsible for credentialing and re-credentialing audits. The Lead Credentialing Coordinator will be responsible for keeping current on all NCQA standards preparing policies and procedures regarding these standards.,. Communicates with contracted facilities and providers on a regular basis. Participates in all facets of MercyCare meetings, which includes scheduling, distributing notices, recording minutes, as appropriate. Performs their duties, as assigned.

Responsibilities

• Maintains high quality, timely and accurate credentialing processes of medical providers, behavioral health providers, and allied healthcare professionals based upon system policies and procedures.
• Manages the entire credentialing process by entering, logging, scanning information into the system for initial credentialing, re-credentialing, add-on applications and maintenance.
• Completes and ensures compliance and delivery of required information to all credentialed providers in a timely manner.        
• Manages all aspects of credentialing and recredentialing in accordance with MercyCare policies and procedures, NCQA Standards, State and Federal regulatory guidelines. 
• Point person for the No Surprises Act (NSA) to ensure regulatory compliance.
• Ensures that all credentials are current and complete pursuant to expiration date of medical licensure, board certification, professional liability insurance coverage, DEA and other pertinent information per MercyCare policy/procedure.
• Manages collection of all information received. Follow-up on missing items/documentation/incomplete forms. Submits follow-up requests, as needed.
• Identifies and evaluates potential red flags and works in collaboration with practitioner(s) to document the issue and practitioner response.
• Advises MercyCare Medical Director of questionable information received and any issues identified during processes.
• Manages sanctions and complaints on a monthly basis and reports any findings to the Medical Director, the Medical Staff Office, and the credentialing committee
• Manages appropriate and accurate entries into applicable systems to activate the practitioner and ensure practitioner inclusion in rosters, directories, and reports.
• Manages all credentials files to ensure that all correspondence is accurately filed; is knowledgeable and current in regard to process.
• Meets and maintains productivity standards as outlined by the department.
• Manages meetings for the credentialing committee, sends out notices, drafts agenda, assembles meeting materials, drafts minutes and follow-up correspondence.
• Maintains information in credentialing database and other systems.
• Builds queries and reports in credentialing software.
• Manages all aspects of the MercyCare provider/facility directory. Ensuring compliance with regulatory standards and NCQA standards.
• Project management for implementation and upgrades of credentialing software
• Point person for in-network adequacy reporting
• Participates in workgroups
• Lead for all NCQA standards and surveysMana
• Development and maintenance of all Standard Operating Procedures for credentialing
• Attends webinars or continued education meetings
• Manages the credentialing sections for HEDIS data collection and annual audit
• Manages delegated audits on an as-needed basis
• Manages the Medicaid re-certification process on an annual basis to ensure compliance as it relates to credentialing
• Assists providers in signing up for access to the MercyCare directory
• Participates in annual review of the MercyCare Provider Manual. Works closely with the MercyCare Contracting department and provider management department to ensure all data is accurate
• Manages surveys to providers to ensure most accurate cultural responsiveness is on file
• Manages weekly, monthly, quarterly and annual reports and distributes information to appropriate departments in a timely manner

Education and Experience

Associate's degree and 1 year of healthcare credentialing experience preferred (healthcare facility, managed care setting, CVO, or medical staff office), OR a minimum of 2 years of experience in credentialing (preferred),  OR a minimum of 3 years of experience in a business support area required

Special Physicial Demands

The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.

In order to perform the demands of this job, the employee may sit for long periods, exerting up to 10 pounds of force occasionally, walking and standing occasionally. The employee is required to frequently reach with hands and arms, finger, handle, talk and hear. Manual dexterity is required.

Culture of Excellence Behavior Expectations