This position is responsible to serve as a primary liaison of contracted Providers and MSO of P.R. departments. The purpose is credentialing, recredentialing and monitoring processes assuring compliance with CMS, NCQA, ASES and MSO of PR Compliance Department regulations.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Responsible for the initial credentialing process requesting and obtaining the requires credentials and assuring compliance with applicable regulations, policies and procedures.
2. Responsible for the recredentialing process, requesting and obtaining the requires credentials and assuring compliance with applicable regulations, policies and procedures, procedures in a Turnaround time less or equal as 36 months, from the last approval Credentialing date.
3. Coordinates/advocates resolution of providers credentialing and recredentialing issues and concerns.
4. Responsible to referred missing, out of PR, dead and out of practice provider to Evaluation Committee for the corresponding cancelation process to avoid recredentialing incompliance TAT.
5. Responsible of the Sanctions, OIG, OPT OUT, Medicare Exclusion and GSA monthly reports verification including individual verification in each credentialing and recredentialing files. In the same way, is responsible of the immediate notification to Supervisor or Manager in case of any provider adverse finding.
6. Responsible for the monthly Board Verification Report and updated in Intranet.
7. Responsible for the monthly Organizational Report and updated in Intranet.
8. Responsible to maintain consistent contact with providers in credentialing and recredentialing status on the way to be able to show the efforts invested in the process.
9. Support the Front End Operator in the scanning and receiving process, as needed.
10. Responsible to create and deliver by mail the provider Credentialing Welcome Letter and Recredentialing Reappointment letter before the Credentialing Committee approval.
11. Responsible to response all issues receive in Credentialing Workbasket according with the establish Turnaround Time.
12. Responsible to maintain the credentialing and recredentiling universe assigned with the update credential information. As requested, the coordinator needs to be able to report the reason of the provider in incompliance and the effort invested, in rapid and easily manner.
13. Special projects could be assigned.
EDUCATION AND EXPERIENCE
Associate's degree (A.D.) in Health or Business Administration and two years related experience.
Ability to read, analyzes, and interprets general business periodicals, professional journals, technical procedures, or governmental regulations. Word processing skills must be proficient and accurate with knowledge of grammar, spelling and punctuation in Spanish and English.
Ability to add, subtracts, multiply and divide in all units of measure, using whole numbers, common fractions and decimals
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
The responsibilities of this position require continuous interaction with colleagues.
1. AVP Provider Internal Operations
4. Provider Internal Staff
1. Customer Service Skills: practicing, valuing and supporting service to both internal and external customers.
2. Time Management Skills: establishing priorities and accomplishing tasks in a timely manner
3. Team Work: ability to work in a team environment to solve or answer questions, issues or concerns.
4. Computer Experience: Microsoft Word, Excel, Power Point and internet.
5. Organizational skills: ability to deal with and motivate employees.
6. Multi task: ability to handle multiple tasks and work under pressure.
7. Must have the capability to maintain excellent communication between staff and management.
8. Detail oriented.
9. Domain analyzing documents.
PHYSICAL AND MENTAL DEMANDS
This position requires working while sitting, standing, talking, hearing and walking in a normal office environment. This position requires weight to be lifted or force to be exerted up to 15- 20 pounds.
ENVIRONMENTAL AND WORKING CONDITIONS
The position requires occasionally working evenings or weekends. The noise in the work environment is moderate and you will be working in a general office environment.
Job Types: Full-time, Temporary
Medical Credentialing: 2 years (Required)