Current Employees:

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Primary Location

Rapid City, SD USA

Department

CS Managed Care

Scheduled Weekly Hours

40

Starting Pay Rate Range

$20.75 - $25.94

(Determined by the knowledge, skills, and experience of the applicant.)

Job Summary

This position is responsible for auditing credentials verifications compliant with NCQA Accreditation standards then directly responsible for enrollment of organizational facilities, service locations, professional groups, physicians, practitioners, and other billing providers with payers where is required in order for the organization to receive payment for services. Managed Care Credentialing and Enrollment Specialists are accountable for maintaining and disseminating accurate plan participation status to operational and billing internal departments to maximize collections in the revenue cycle management process. Function as subject matter expert for payer credentialing and enrollment representatives to ensure health system providers are fully credentialed and loaded as participating providers with all applicable government and commercial payers.

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

*Supportive work culture

*Medical, Vision and Dental Coverage

*Retirement Plans, Health Savings Account, and Flexible Spending Account

*Instant pay is available for qualifying positions

*Paid Time Off Accrual Bank

*Opportunities for growth and advancement

*Tuition assistance/reimbursement

*Excellent pay differentials on qualifying positions (extra pay for working evening, nights or weekends)

*Flexible scheduling

Job Description

Essential Functions:

• Directly responsible for oversight and collection of accurate credentialing of organizational providers, facilities and ancillary services.
• Oversight and collection of documentation necessary for payer enrollment of complex hospital groups and services compliant with hospital system policies and accreditation sources such as NCQA, CMS and others.
• Will perform primary source verification using pre-approved sources consistent with hospital system credentialing policies as needed to support credentialing and enrollment functions
• Ensure compliance with applicable regulatory requirements, accreditation standards, payer policies, and governing documents.
• Obtain application signatures from the authorized signatory and provide all required supporting documentation. Submit applications and follow up diligently to ensure timely processing. Respond to deficiency notifications in a timely manner. Follow up diligently on provider addition requests and communicate provider changes, corrections, and terminations. Continuously monitor enrollment process for improvements. Collaborate with Legal and Accreditation to ensure regulatory and compliance requirements are met.
• Responsible for delegated credentialing policy interpretation and compliance. Responsible for annual payor credentialing file audits. Oversees delegated credentialing roster submission and tracking. Work with delegated payer contacts to address concerns within the delegation process while cultivating relationship with delegated payers.
• Works collaboratively with Credentialing Manager and Coordinator to promote data integrity and to optimize effectiveness of the Credentialing database, ensuring consistency in data entry rules. Supports the implementation of new database modules applicable to Managed Care. Implementation includes data migration and validation, as well as data mapping to demographic reports, participation reports, and training.
• Functions as the subject matter expert for the credentialing department. Provides training related to credentialing and payer enrollment that enhances knowledge, develop skills and enrich the team.
• Excellent interpersonal skills and ability to work efficiently with internal and external customers. Maintain positive working relationships with payer representatives, providers, and all Monument Health internal departments.
• All other duties as assigned.

Additional Requirements

Required:

Education - High School Diploma/GED Equivalent in General Studies

Preferred:
Education - Associates degree in Healthcare

Certification - Certified Provider Credentialing Specialist (CPCS) - Accredited University or accredited training professionals

Experience - 2+ years of Healthcare Experience; 2+ years Management Experience; 2+ years Credentialing Experience; 2+ years Billing/Collections Experience; 2+ years Medical Terminology Experience

Physical Requirements:
Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

Job Category

Business Administration

Job Family

Business Services

Shift

Employee Type

Regular

15 Corporate Services Division

Make a difference.  Every day.

Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.