Credentialing Specialist

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Job Type

Full-time

Description

Who We Are:

TwelveStone Health Partners is focused on the medication needs of patients with chronic, complex and rare conditions. For more than 35 years, TwelveStone Health has been dedicated to finding new ways to deliver care designed around the patient. Chronic conditions include Multiple Sclerosis, NMOSD, Myasthenia Gravis, CIDP, ITP, Migraine Prevention, Crohn's Disease, Ulcerative Colitis, Plaque Psoriasis, Alpha 1 Antitrypsin Deficiency, Primary Immunodeficiency, hATTR Amyloidosis, Thyroid Eye Disease, and many others.

For patients, we provide access to the most advanced medications, along with the personal and financial support patients need to live with chronic conditions. For providers, we simplify treatment for complex conditions by eliminating the administrative and clinical burdens placed on your practice when patients need innovative specialty medications.

TwelveStone Health Partners supports the transition from acute to post-acute care environments and the journey from sickness to health. We are currently licensed in 50 states.

Summary:

We are currently hiring for the position of Credentialing Specialist. The Credentialing Specialist is responsible for all administrative aspects of credentialing services and verifying submitted credentialing documentation for individual practitioners, infusion centers and home infusion therapy contracts. The Credentialing Specialist will meet all credentialing turnaround time requirements, by submitting accurate and complete applications. The Credentialing Specialist will abide by all policies and processes to meet all state, regulatory, health/safety, and compliance guidelines and for maintaining accurate and up to date provider information.

Essential Duties & Responsibilities:

• Manages the completion and submission of individual practitioner, facility and PBM credentialing / re-credentialing applications, approval, denial, termination letters, and accurately loading provider information in the Credentialing database (CAQH, Availity, etc.) & maintaining accurate information in the provider tracking logs (excel). Enroll providers, infusion centers and home infusion pharmacy in State Medicare/Medicaid. Responsible for outreach to pertinent parties to obtain any needed documents that go along with credentialing applications, as directed. Escalates any missing items to leadership in efforts to stay on task and avoid credentialing lapses. Performs tracking and follow-up to ensure credentialing information is accurate, updated and/or resolved updated, in a timely manner. Performs follow-up with insurance State Medicare / Medicaid and payors via phone, email, or website to resolve payor credentialing issues. Completes yearly revalidations and other requests to ensure accuracy and avoid delays in payment and obtaining authorizations. Understands specific application requirements for each payor including pre-requisites, forms required, roster form completion requirements, supporting documentation (DEA, CV, Accreditation, etc.) and regulations.
• Creates and maintains provider files in compliance with the organization's policies. Maintains documentation and reporting regarding provider enrollments in process. Retains records related to completed payor credentialing applications. Ensures data integrity and confidentiality is maintained in related credentialing records. Performs quality checks and proactively verifies enrollment of all providers and lines of business in with payors, CMS and State Medicaid. Establishes close working relationships with Compliance, Contracting and Revenue Cycle as well as payor contacts. Abides by all policies, procedures, and work instructions for the credentialing function.
• Coordinate credentialing and re-credentialing processes, maintaining task grids and systems to assure follow up and completion. Continuous monitoring of payor enrollment to ensure accuracy of all provider information. Maintain communication with all internal departments. Responsible for managing Credentialing email. Assists in goals and performance standards management.
• Other duties and special projects as assigned.

Requirements

Education: High School Diploma or GED required, Associates Degree a plus

Experience: 2+ years of payor credentialing experience, or 3+ years of healthcare related experience, preferred. Previous relevant healthcare experience including, but not limited to, billing, intake, processing, compliance, contracting, etc.

Confidentiality: Maintains strict confidentiality regarding protected health information and understands and adheres to HIPPA Privacy & Security policies and procedures. Maintains strict confidentiality regarding provider and practice information.

Functional Competencies: Attention to detail, critical thinking, prioritization, problem solving, approachable, phone etiquette, dependable, verbal, and written communication, teamwork, cooperation, collaboration, judgment.