Fallon Health Provider Credentials Specialist-Health Insurance! in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Position Summary: Performs a variety of credentialing/recredentialing activities, such as processing provider applications, coordinating/conducting office site reviews, responding to internal inquiries regarding providers and maintain credentialing database and files. Responds to Provider inquiries for information and requests, working closely with Provider Relations, Contracts and other internal departments to resolve any issues. Responsible for carrying out credentialing activities and assignments of a very confidential nature. Works under general supervision.
Primary Job Responsibilities:
Managing all physicians, dental and allied health professional correspondence in regards to credentialing/recredentialing such as: incoming mail, verification of provider credentials such as education and training, licensure, board certification, hospital privileges and NPDB in compliance with NCQA, CMS and MA Board of Registration in Medicine. Responsible for individual tracking of all files in process and timely turnaround time.
Process re credentialing applications (every 2 yrs.).
Initiate correspondence for credentialing and re credentialing of all providers and all follow-up directly with providers.
Tracking of all providers in process to completion using Network Pro.
Respond to all inquiries from providers and internal departments regarding status of providers in process or issues with providers already credentialed.
Entry of all provider information into physician and communication to pertinent departments of any changes in information.
Entry of all providers to be credentialed/recredentialed each month into a listing for communication with pertinent departments.
Preparation of all second level reviews for Credentials Committee (problematic files with significant follow-up issues).
Audits credentials files identified as outliers, on a monthly basis, for inclusion in discussion at staff meetings.
Audits data reports from Networks Pro for accuracy of information.
Liaise between existing IPA/PHOs to maintain accurate information regarding the credentialing of providers.
Awareness of all new regulatory issues for integration into the credentialing/recredentialing process.
Represent department at meetings.
Responsible for CAQH & CVO rosters.
Maintain HCAS process.
Monitor and follow-up with the non-responder process.
Assist in Fallon Health delegated oversight audits.
Process provider terminations in NWP and QNXT for credentialing & recredentialing.
Maintains proficient knowledge of credentialing processes, in accordance with company policies as well as the National Committee for Quality Assurance (NCQA) standards in an effort to ensure accreditation.
Ad hoc reporting.
Education, Licenses, certification and experience requirements:
Education : Bachelors degree, or equivalent training and experience
Experience: Minimum of two years in healthcare setting
Job ID 5790
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