Managed Care Provider Enrollment Specialist

Position Summary

At Stony Brook Medicine as a Managed Care Provider Enrollment Specialist you will work under the oversight of the Director of Managed Care Enrollment and join a team of professionals representing Stony Brook Medicine* and its Clinical Integrated Network. As a member of the Managed Care Enrollment (MCE) Team you will be responsible for coordinating and facilitating managed care provider and facility enrollment and network participation activities on behalf of SBM.

*For purposes of this position Stony Brook Medicine includes the following entities: Stony Brook University Hospital Stony Brook Childrens Hospital Stony Brook Southampton Hospital Stony Brook Eastern Long Island Hospital Stony Brook Clinical Practice Management Plan Inc. and Meeting House Lane Medical Practice PC.

Duties of a Managed Care Provider Enrollment Specialist may include the following but are not limited to:

• Responsible for the data intake of SBM providers for the purpose of enrolling a provider in a managed care organization or other payer (MCO) network. Work collaboratively with SBM providers to collect capture and process the following information: Enrollment Packet with supporting documentation; Department Managed Care checklist; Demographic data; and Participation Information. For MCOs not under a delegated agreement: Complete enrollment applications paper change forms eMedNY PECOS CAQH profile or other method established by the MCO within time frames required by MCO.
• Coordinate provider enrollment activities to ensure timely provider submissions to MCOs e.g. Delegated/Non-Delegated (CAQH) providers. Notify the MCO of provider demographic/participation statuses. In accordance with the terms of the delegated credentialing agreement providers are to be enrolled within ninety (60) days of roster submission. Inform Director of Enrollment of MCOs non-compliance. A provider enrollment roster should be sent at a minimum once per month to the MCO or as required by the delegated credentialing agreement in place between the MCO and SBM. Upon receipt of the providers participation status notify key stakeholders of the ID number and effective date. Keep accurate communication records. Upon notice of a change in a providers demographic data licensure or certification update delegated credentialing electronic roster for each assigned MCO and email to MCO within twenty-four (24) hours of receipt of demographic change. Upon notice of a providers termination from SBM update delegated credentialing electronic roster and email to MCO within twenty-four (24) hours of receipt of termination notice. For MCOs not under a delegated agreement: Complete paper change form CAQH profile or other method established by the MCO within timeframes required by MCO.
• Gather and review data for reporting purposes to meet MCE delegated credentialing contractual obligations. Depending on MCO monthly quarterly semiannual and/or annual reporting of provider database roster reviews are a requirement of the delegated credentialing agreement. Upon notice from the MCO furnish the report or roster review within the timeframe required by delegated credentialing agreement. At the request of the MCO review MCOs provider database for accuracy. If incorrect follow MCOs policy and procedure for reporting incorrect or incomplete information.
• Conduct quality assessments for all databases that are created and/or maintained by MCE. If the findings are unsatisfactory contact the SBM provider/MCO to discover the reason. Make updates/corrections where possible. Escalate all questions and inquiries to the Director of Enrollment. Maintain the integrity of all MCE databases by continuously auditing the data that is collected and distributed. Communicate effectively with the MCE team and other key stakeholders to gather assess and resolve inconsistencies. Some examples of data reviews that assist in maintaining the data integrity are as follows: Quarterly Database Review Internal and External Roster Review Monthly Expirables Management Review Service Location Review Billing Address Review.
• Maintain vital relationships with MCOs by addressing all inquiries in a timely fashion. Work with SBM team members to resolve various inquiry types that are related to provider enrollment. Such as but are not limited to the following: Claim denials; Authorization issues; Provider participation inquiries; Transferring of member panel inquiries; and Provider location inquiries. As needed direct questions and escalations to the Director of Enrollment.
• For non-Clinical Practice provider groups review analyze and report on various data sets deemed necessary by the department. Such as but not limited to the following: Database Update Review Tracker and/or Report MCE Roster Submission Tracker and/or Report Monthly Status Report.
• Attend participate and/or facilitate professional development activities. Actively participate in workshops meetings training programs and/or other professional activities deemed necessary by the Director of Enrollment.
• Develop and distribute notifications to internal SBM team members. Work collaboratively with MCE Team members to develop and distribute the departmental newsletter(s) and/or other forms of notifications as outlined in departmental workflows and/or advised by the Director of Enrollment. As appropriate facilitate regularly scheduled meetings with MCOs to build and maintain open lines of communication and to foster collaboration for provider enrollment and facility credentialing/re-credentialing initiatives.
• As it pertains to credentialing maintain current knowledge of NCQA TJC CMS and NYS laws and regulations. Review the following for MCOs: newsletters policy updates and other notifications that directly affect MCE Team workflow(s). Direct questions regarding revised law regulatory guidelines and MCO correspondence with the Director of Enrollment.
• Conduct data entry for MCE in Symplr Provider credentialing software. Responsible for the timely processing and tracking of provider enrollment data e.g. Provider ID numbers and Effective Dates. Add update and maintain the integrity of the data that is entered into the electronic credentialing database daily. Ensure that all data is current. Escalate all database expirables issues or data integrity issues to the Director of Enrollment. For providers not in Symplr Provider conduct data entry in applicable electronic database. Add update and maintain the integrity of the data that is entered into the electronic database. Ensure that all the data is current.
• Coordinates and implements credentialing activities to assist SBM facilities with the completion of MCO facility credentialing/re-credentialing applications for MCO network contract offerings; monitors and follows-up as needed. Conduct data entry for MCE in the electronic database. Responsible for the timely processing and tracking of facility demographic data including services rendered at each facility location. Add update and maintain the integrity of the data that is entered into the electronic facility credentialing database daily. Ensure that all data is current. Conducts provider managed care enrollment and facility credentialing and re-credentialing activities; communicates with practice plan administration or hospital staff to obtain requisite credentialing information to facilitate timely completion and submission of required documents. Escalate all database issues or data integrity issues to the Director of Enrollment.
• Establishes and manages relationships with internal team members as it relates to PCMH.
• Monitors to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards.

Qualifications

Required Qualifications:

• Bachelors Degree
• Minimum of three (3) years of direct experience in enrolling clinical health care providers either within a health care delivery organization or group of moderate or significant size or on behalf of a managed care organization or payer.
• Direct experience with NYS Medicaid and Medicare enrollment and recertification.
• Experience setting up and managing the Council for Affordable Quality Healthcare (CAQH) profiles.
• Knowledge of NCQA TJC CMS and New York State Education Department and New York State Department of Health Laws as they pertain to credentialing.
• Demonstrate project management skills and be proficient in database management.
• Demonstrate background in healthcare credentialing policy and management.
• Strong interpersonal and communication skills proven research and analytical skills and ability to handle multiple priorities.
• Ability to follow read and interpret managed care delegated credentialing contracts.
• Proficient in the use of Symplr Provider Microsoft Office software and Google software.

Preferred Qualifications:

• MBA MHP MPA or equivalent advanced degree.
• Minimum of five (5) years of direct experience enrolling health care providers.
• Minimum of five (5) years of direct experience with managed care enrollment or credentialing and re-credentialing.
• Minimum of five (5) years of direct experience with managed care facility credentialing and re-credentialing.
• Knowledge of medical staff credentialing processes procedures and resources.

Special Notes:Resume/CV should be included with the online application.

Posting Overview:This position will remain posted until filled or for a maximum of 90 initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted additional applications will be considered for the posted position; however the posting will close once a finalist is identified and at minimal two weeks after the initial posting date. Please note that if no candidate were identified and hired within 90 days from initial posting the posting would close for review and possibly reposted at a later date.

• Stony Brook Medicine is a smoke free is strictly prohibited anywhere on campus including parking lots and outdoor areas on the premises.
• All Hospital positions may be subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection which may prohibit the wearing of facial hair.
• This function/position may be designated as essential. This means that when the Hospital is faced with an institutional emergency employees in such positions may be required to remain at their work location or to report to work to protect recover and continue operations at Stony Brook Medicine Stony Brook University Hospital and related facilities.

Prior to start datethe selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicines Employee Health Services*
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4panel drug screen*
• Meet Regulatory Requirements for pre-employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

*The hiring department will be responsible for any fee incurred for examination.

Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning and workingenvironment. All qualified applicants will receive consideration for employment without regard to race color national origin religion sex pregnancy familial status sexual orientation gender identity or expression age disability genetic information veteran status and all other protected classes under federal or state laws.

If you need a disability-related accommodation please call the University Office of Equity and Access at .

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Stony Brook University Hospital consistent with our shared core values and our intent to achieve excellence remains dedicated to supporting healthier and more resilient communities both locally and globally.

Anticipated Pay Range:

The salary range (or hiring range) for this position is $93636 - $109242 / year.

The above salary range represents SBUHs good faith and reasonable estimate of the range of possible compensation at the time of posting. The specific salary offer will be based on the candidates validated years of comparable experience. Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired.

Some positions offer annual supplemental pay such as:

• Location pay for UUP full-time positions ($3400)

Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave health plans and a state pension that add to your bottom line.