Provider Enrollment & Credentialing Representative

Job Functions Duties Responsibilities and Position Qualifications:

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Accountable for the initiation of new credential files ensuring the completeness of a new application as the first step in the credentials verification process and participating in verification of credentials through correspondence phone contact internet sites and any other third party vendor. Be a first-line communicator with physicians healthcare entities external verification sources and services. Responsible for maintaining a current and accurate system-wide data repository for provider information. This includes establishing and updating provider files through both an online and paper application and reapplication process obtaining and evaluating primary source verification of provider credentials maintaining currency of expired credentials/licensure and facilitating the communication of significant findings and process milestones to customers throughout the Aurora system. Responsibilities also include the application and reapplication process for providers requesting Hospital Medical Staff Membership and clinical privileges as well as responsible for completion of provider applications and follow-up to enroll employed and contracted providers into multiple managed care plans as identified by location. Must be able to work on multiple daily tasks with efficiency and high-quality accuracy while handling multiple internal and external customer communications. Plan work to meet regulatory and customer defined deadlines which requires coordination to minimize redundancy of work when multiple organizations share common providers.

• Initial credentialing and re-credentialing of physicians.
• Obtains Medical Licenses as required as well as ensures that all Aurora Medical staff meet and maintain active licensure.
• Oversee the maintenance of all certifications required to successfully license and credential all physicians with the exception of the laboratorys CLIA licenses
• Coordinates and monitors the review and analysis of practitioner applications and accompanying documents ensuring applicant eligibility.
• Conducts thorough background investigation research and primary source verification of all components of the application file.
• Identifies issues that require additional investigation and evaluation validates discrepancies and ensures appropriate follow up.
• Prepares credentials file for completion and presentation to Entity Credentialing Committees ensuring file completion within time periods specified.
• Responsible for CAQH files for providers to ensure completion and maintain revisions/updates
• Processes requests for Provider Enrollment ensuring compliance with criteria outlined in descriptions for both commercial and Government payers.
• Responds to inquiries from other healthcare organizations interfaces with internal and external customers on day-to-day credentialing issues as they arise.
• Coordinate all managed care credentialing activities to ensure provider participation status. Credentialing activities require substantial contact with outside agencies.
• Utilizes Intellicred credentialing database optimizing efficiency.
• Remains current on policies affecting physician credentials and enrollment processes.
• Ability to interact positively in a team environment demonstrating superior teamwork skills.
• Maintains strictest confidentiality
• Complies with all State Federal professional regulations as well as company and departmental rules polices and procedural manuals
• Adherence to HIPAA Safety and OSHA Regulations
• Performs other duties as assigned

All you need is:

• Bachelors Degree or the equivalent years of experience.
• Four years related experience; or equivalent combination of education and experience
• Ability to solve complex problems to support the planning organizing and coordinating of provider payer credentialing
• Knowledge of medical terminology insurance billing credentialing and licensing processes as demonstrated by work experience and education
• Must be able to effectively respond to questions from managers employees and outside entities
• Evidence of the practice of a high level of confidentiality

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Sonic Healthcare USA is an equal opportunity employer that celebrates diversity and is committed to an inclusive workplace for all employees. We prohibit discrimination and harassment of any kind based on race color sex religion age national origin disability genetics veteran status sexual orientation gender identity or expression or any other characteristic protected by federal state or local laws.