Payer Enrollment Representative

Job Summary

Administers the credentialing process to coordinate, monitor, and maintain facility and provider credentialing while supporting other department initiatives and projects. Analyzes and resolves problems related to physician enrollment and other activity for WVPHO members. Ensures that physicians are linked correctly to plans and products for correct claims payment and revenue. Responds to requests for verification and information from internal and external customers.

Responsibilities

• Follows up on physician enrollment status with contracted plans by building effective relationships with plan representatives to ensure that WVPHO member activities are given priority processing.
• Evaluates reported claim problems to determine if problem is related to enrollment or other error. Resolves enrollment error, provides plan with documentation of error and obtains plan commitment to reprocess claims. Refers non-enrollment issues as appropriate.
• Identifies data disparities between group contracted plan sources and Managed Care database to limit negative impact on revenue, precertification and referral denials and patient procedure cancellations. Works with plan representatives to correct errors.
• Identifies delays in credentialing, enrollment errors and claims payment problems and works with plan representatives to further identify root causes and resolve problems.
• Maintains internal database and external web module database; updates physician information in group contracted managed care plans, Medicare, Medicaid, and non-contracted carriers including demographic information, addresses changes and terminations.
• Coordinates enrollment and credentialing for delegated and non-delegated plans, Medicare, and Medicaid including but not limited to enrollment, payer terming and demographic changes.
• Follows organizational and regulatory requirements. Identifies potential problems. Proactively assists in problem resolution.
• Provide world class customer service via phone, virtual and in person meetings and email correspondence
• Ability to coordinate and complete multiple tasks, utilizing time management and organizational skills

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company's attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education

• Bachelor's Degree (Required)

Education: Bachelor's degree in business or healthcare administration.

Substitution: May substitute 4-5 years of credentialing and project management in a healthcare environment for the Bachelor's degree

Comment: • Demonstrated experience with database and supporting software including Microsoft Word, Excel and Microsoft Access. Able to perform essential functions for reporting purposes and data analysis (i.e., Create data, data sorting filtering for plan-database comparisons and reconciliations). • Excellent problem solving, communication and interpersonal skills to effectively mediate and resolve issues in a timely and cost-effective manner. • Demonstrated project management skills. • Demonstrated ability to prioritize workflow to achieve time sensitive goals. • Credentialing and/or Medical Staff Office experience preferred. • Strong project management skills. • Demonstrated human relations and effective communication skills.

Credentials

• No Certification, Competency or License Required

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Northgate-400 Association Dr.

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org