Credentialing Co-ordinator & Audit Compliance

Job ID: 10-2022-209

JOB DESCRIPTION

Specialty Eye MDs is a large and comprehensive Ophthalmology practice in New Jersey. We are the recognized leader in vision care treating adults and children.

JOB TITLE: CREDENTIALING & AUDIT COMPLIANCE CO-ORDINATOR

POSITION SUMMARY:

The Credentialing Coordinator performs clerical functions to maintain active status for all providers in both Medical & Routine Vision Plans as directed, resolution of problems to ensure a clean billing process, and works with others in a team environment.

For Audit Compliance: Take all communication from Insurance Carriers for chart review. Comply with all data (chart retrieval from all locations) and coordinate with Physicians to successfully complete Medical Audits within the deadlines. Maintain Pre-Certification requirements of Insurance Carriers for commonly performed office procedures.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

The Credentialing Specialist is responsible for maintaining active status for all providers by successfully completing initial and subsequent credentialing packages as required by hospitals, surgery centers, commercial payers, Medicare and Medicaid.

• Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications
• Maintain internal provider grid to ensure all information is accurate and logins are available
• Update each provider’s CAQH database file timely according to the schedule published by CMS
• Apply for and renew annually all provider licenses; Professional, DEA, Controlled Substance
• Keep up-to-date Pre-Certification requirements of Insurance Carriers for office procedures & Re-attestation
• Complete revalidation requests issued by government payers
• Complete credentialing applications to add providers to commercial payers, Medicare, and Medicaid
• Complete re-credentialing applications for commercial payers
• Credential new providers and re-credential current providers with hospitals at which they hold staff privileges
• Work closely with the Revenue Cycle Manager and billing staff to identify and resolve any denials or authorization issues related to provider credentialing
• Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases
• Other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES 

• Knowledge of provider credentialing and its direct impact on the practice’s revenue cycle
• Excellent computer skills including MS Office Suite, Excel, Power Point, Word, and Internet use
• Detail oriented with superior organizational skills
• Plans and prioritizes to meet deadlines
• Excellent customer service skills; communicates clearly and effectively

EDUCATION/EXPERIENCE REQUIRED

• Associate Degree or equivalent, preferably in Health related field.
• 2 years experience in a Medical practice Business Office is required.

PREFERRED EXPERIENCE:

• Prior Credentialing experience in a medical office.
• Highly preferred Certified Provider Credentialing Specialist (CPCS) designation from National Association of Medical Staff Services (NAMSS)