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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

This position shall perform functions related to the enrollment in healthcare plans for practitioner and facility members of the Northeast Georgia Health Partners Network. This includes the processing for all self-funded TPA contracts, delegated payors, Medicare Advantage and Medicaid CMO's for initial credentialing & re-appointments. This position may perform credentialing functions from time to time as deemed necessary. This position shall effectively communicate pertinent information to all necessary individuals and entities in a timely and accurate manner, both internal and external to the department. This position shall possess knowledge of widely used credentialing and enrollment concepts, practices, and procedures. Relies on experience and judgment to plan and accomplish daily work. Works under general supervision.

Minimum Job Qualifications

• Licensure or other certifications:

• Educational Requirements: Bachelors Degree

• Minimum Experience: Two (2) years of experience in the area of managed care, to include credentialing, provider payor enrollment and/or provider relations

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience: Five (5) or more years' experience in health care. Experience with enrolling providers in commercial and government payor groups.

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Experienced working with Medicare, Medicare Advantage, Medicaid, Medicaid CMOs and other governmental payors in enrolling providers

• Accustomed to working with commercial and governmental payors in a delegated arrangement and responding to deadlines

• Experienced in credentialing providers with commercial plans following NCQA accreditation standards

• Demonstrates a solid understanding of the various operational aspects of managed care to include provider enrollment, credentialing and provider relations

• Must be detailed oriented with excellent organizational and computer skills

• Must be able to make logical judgments, utilizing independent decision-making skills appropriately

• Strong written and verbal communication skills and the ability to communicate effectively with people on all levels

• Demonstrate ability to function as part of a team, as well as be highly self-motivated

• Must have ability to handle multiple projects at the same time, establish priorities and perform under deadline pressures

• Exemplifies the organization's customer service standards.

• Improves work processes

• Meets all mandatory educational requirements

• Complies with confidentiality rules, polices, and regulations in all aspects of the job

• Demonstrates working knowledge of safety practices

• Promotes teamwork

• Meets NGHS attendance standards

• Utilizes financial resources effectively

• Responds positively to change regarding work

• Demonstrates respect for co-workers

Essential Tasks and Responsibilities

• Shall prepare documents to successfully enroll all provider types in payor plans contracted with Health Partners for both commercial and governmental plans.

• Takes the lead with payors in monitoring the progress of enrollment. Notifies management of payor noncompliance.

• Follows-up with the provider, the credentials verification office and/or NGPG recruitment to secure missing documents for credentialing and enrollment purposes.

• Monitors provider non-compliance with enrollment requests and notifies management of delays that can impact reimbursement.

• Responsible for provider and payor roster management.

• Monthly, or more often as needed, prepares and submits delegated rosters to payors in accordance with delegated agreements to ensure timely effective dates for billing and payment purposes. This includes new and changed information. Monitors receipt and follow-through.

• On an ongoing basis, tracks timeliness of provider loads by payor to include date submitted, date confirmation received, error rate and corrections needed. Reports non-compliance to management for further direction. Retains communication in an orderly fashion for reference purposes.

• On a monthly basis, audits provider loads once confirmed by the payor for accuracy. Report, by way of written correspondence, the errors that need to be corrected to the payor. Report findings to management. Monitor progress and resolution. Schedule conference call and/or meetings with payor representatives to address issues.

• Authors and sends correspondence to payors to maintain current provider information including, but not limited to, changes in practice addresses, contact information, name changes, board status and resignations.

• Sends out provider demographic update requests as directed, to the HP/HP2 network members, to maintain accurate provider data within the network's data systems and with the networks contracted payors.

• Amends and updates the HP master spreadsheet, organizational documents, the website, and credentialing and enrollment systems with physician and/or physician office information with regards to additions, updates, terminations, and other information that is supplied to the HP payors for accurate claims payment.

• Follows-up on rejected documents or loading from the payors. Corrects and resubmits on a timely basis. Retains records for reference purposes.

• Completes and submits payor specific enrollment spreadsheets for existing providers that want to add additional practice locations or are moving from one practice to another in support of the payment process.

• Monitors receipt of payor effective date notices. Contacts payors to follow-up on enrollment loading status. Enters HP effective dates into the Medicred payor enrollment system. Notifies key personnel when updates are made.

• Enters and updates all provider demographics into the appropriate data repositories for tracking and reporting purposes. Notifies the CVO and/or others as necessary when changes are needed, and special reports need to be captured and configured.

• Maintains an accurate distribution list to include all persons that shall receive on-going information from Northeast Georgia Health Partners.

• Maintains files in an orderly and secure fashion. Creates e-files to house enrollment documents and related correspondence. Initiates a provider enrollment tracking form for each provider to monitor progress.

• Supports the NCQA standards and accreditation process.

• Serve as a liaison between the provider, staff and Health Partners in support of resolving credentialing and payor enrollment issues that arise during the initial and/or re-credentialing processes.

• Builds and maintains Health Partners relationships with existing, potential and new network providers and staff.

• Will cross train and perform other duties as assigned within the department in the following areas credentialing, data integrity and provider relations.

• Schedules, organizes, and coordinates all in-services and educational material for Health Partners providers regarding processes and procedures of various payors that contract with the Northeast Georgia Health Partners Network.

• Shall routinely compose emails and other written material using proper grammar and sentence structure.

• Shall conduct provider office visits and or other orientation and onboarding activities as directed.

• Shall organize and draft material for the Newsletter as directed.

• Supports management in all aspects of provider enrollment to include reporting, meeting attendance and departments projects as needed.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.