UnityPoint Health PHO Payer Enrollment Network Coordinator in West Des Moines, Iowa
Prepare and submit payer credentialing applications to non-delegated payers and provider roster updates delegated payers on behalf of providers and clients that contract for the service. Monitor status of payer credentialing applications, performing follow-up actions as necessary. Maintain provider information in the system wide credentialing database in network management module.
This position is responsible for coordinating and maintaining the Medimore, Inc. provider network, including managing the credentialing and re-credentialing process in accordance with the Central Verification Office (CVO) policies and procedures, Medimore, Inc.’s. policies and procedures, Delegated Payer’s policies and procedures and regulatory agencies. This position shall serve as a liaison between payers, CVO, providers, and regulatory agencies.
Payer Enrollment and Database Accountability
Accurately record all provider information in the network management module for the system of record
Coordinate all aspects of provider enrollment for client medical group, individual practitioners, and facility enrollment with payor programs such as Medicare, Medicaid, Wellmark, Blue Cross Blue Shield, UnitedHealthcare, Aetna, etc.
Data entry and upkeep of all network participating facility/ancillary providers
Credentialing and re-credentialing of all network participating facilities/ancillaries.
Responsible for the completion and submission of all payer initial and re-credentialing applications in the required format in coordination with the CVO process
Utilize the online process tracking features of the credentialing record system.
Ensure all provider enrollment data is properly controlled and tracked to ensure applications are approved or denied within established standards of timeliness.
Follow-up with carriers on issues or questions related to enrollment submissions.
Review applications to ensure compliance with appropriate entities, ensuring they are appropriately signed and completed.
Assist with auditing of data entered in the provider data
Compile and submit to payer the necessary applications and attachments, including enrollments with Medicare PECOS system.
Monitor status of payer applications with payers to ensure timely enrollment approvals.
Coordinate with IT the creation and maintenance of provider payer panel records (EDI table) in Epic.
Assist with researching claim issues brought forward from clinic administrators,customer service staff, and the central billing office.
Monitor claim denial reports to further investigate payer panel roster errors.
Responsble for coordinating initiation of payor credentialing with the CVO for provider payer credentialing and enrollment
Responsible for research and communication of contracting information.
Inform billing agents of new providers and billing numbers when obtained from payers.
Scan completed provider enrollment paperwork into provider files.
Process provider name changes with payers, as applicable.
Process additional practice locations with payers as notified by Clinic Administrators, CVO, or electronic ticket notification system.
Deactivate/Terminate inactive providers from payers.
Deactivate/terminate inactive providers from appropriate Network Manager products and locations.
Maintain an efficient and effective confidential filing system for Medimore, Inc. provider files.
Identify and report any non-compliance or credentialing issues to the PHO Network Manager and CVO Credentialing Manager, if applicable for further research and communication to UPH Medical Staff Offices.
Establish regular communication and respond to the CVO, health professionals, provider representatives, or other essential departments the status of applications, the status in the credentialing process and the status of participation with health plans.
Enter and maintain accurate provider data in the organization credentialing database (Network Manager) for payor credentialing purposes.
Maintain constant awareness of delegated payers and non-delegated payers contracting relationships.
Maintain a broad understanding of managed care contracting process and the effects changes may have on provider network enrollments.
Comunication and coordination with UPH ACO Department the onboarding of providers for network utilization tracking.
High school graduate or GED equivalent required
Associates degree preferred
Minimum of 2 years of experience in the field of payer credentialing and enrollment, provider billing services, or health clinic customer service positions.
Knowledge of the managed healthcare industry.
Proficient in Microsoft Office Suite.
Knowledge of regulatory agency standards (i.e. NCQA, URAQ, JCAHO, etc)
Excellent communication skills both written and verbal
Current experience with submission of payer applications preferred
Excellent Interpersonal skills
Strong communication skills – written & verbal
Demonstrated ability to adapt to change
Requisition ID: 2020-80717
Street: 1776 West Lakes Pkwy
Name: 9010 UnityPoint Health System Services
FTE (Numeric Only; Ex. 0.01): 1.0
FLSA Status: Non-Exempt
Scheduled Hours/Shift: Days
External Company URL: http://www.unitypoint.org