Payor Credentialing Specialist

PURPOSE AND SCOPE:

Knowledgeable, experienced specialist responsible for initial verification for all existing and new providers to allow the practitionerto admit and treat patients atFMCNA locations. Collaborates with external credentialingagent to ensure credentialing processis completed. Ensures all provider credentialing verification is performed in accordance with regulatory and accreditation standards and FMCNA policy and procedure. Performs audits of internal FMCNA Provider Database and FMCNA provider information compiled by the external credential verification agent to ensure that credential verification is completed in a timely manner according to all regulatory and company requirements. Supports FMCNA's mission, vision, core values and customer service philosophy. Adheres to the Compliance Program, including following all regulatory and division/company policy requirements.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Under limited supervision, applies considerable credentialing knowledge and skills to perform a wide range of moderately difficult tasks and assignments requiring judgment in resolving issues and/or in making recommendations. Normally receives no instruction on routine daily work, and general instructions on newly introduced assignments
• Contacts are frequently with individuals representing other departments, and/or representing outside organizations.  Contacts involve obtaining or providing information or data on matters of moderate importance to the function of the department or which may be of a sensitive nature.
• Perform provider credentialing verification tasks to facilitate compliance with Medical Staff by-laws regardingthe verification of a minimum set of a practitioner's credentials required prior to the patient receiving their second treatment. Responsiblefor tasks related to the three year cyclical verification process of all active practitioners.

• Apply knowledge regarding national accreditation standards, internal medical staff bylaws and other related policies and regulations to perform functionspertaining to the provider credentialing process for the assigned division. This includes but is not limited to:

  • Obtaining practitionerlicense information from publicly available state/government agency websites, the National Provider Databank, and other 3rdparty certification groups such as the American Board of Internal Medicine.
  • Completing and processing all initial credential applications for new providers/practitionersand credential verification applications for existing providers in a timely and accurate manner.
  • Conducting follow-up as needed, acting as the primary liaison for FMCNA locations, practitioners, and the FMCNA third-party credentialing agent to ensure that all credentialing is completed within the required timelines and that each provider meets federal and state regulations as well as FMCNA internalrequirements.
  • Maintaining and updating the database on individual provider credentials' status, tracking pending/completed applications, and maintaining a complete and accurate database of historical applications. Provides regular reports and updates to pertinent field operations managementand Director of Operations Monitoring.
  • Communicating with providers regarding credentialing status, providing updates and obtaining additional information as required.
• Educate and inform field staff responsible for reporting new providers regarding their responsibilities in the credential verification process. Explain the credentialing requirements, provider specific information, informationregarding the FMCNA third-party credential agent, regulations and industry standards for credentialing of health care providers and other information as applicable.
• Continually audit and analyze the credentialingprocess to identify deficiencies in controls and to identify process/workflow issues recommending improvements to managerand implementing if approved.
• Review internal Provider Databaseinformation and databaseof FMCNA provider informationcompiled by external credential verification agent to identify and take appropriate action where requiredto correct areas of noncompliance with company policy. This includes reporting to the appropriate stakeholders identified deficiencies in provider applications, providing information regarding providers non-compliant with verification policies, notifying the appropriate personnel regardingexpired board certifications, and other requirementsituation updates as applicable.

• Generate various standard and ad hoc reports from database:

  • Prepare project status reports as required, detailing progress of credential verification status of individual practitioner credential applications for each division, and reporting variances and trends in the credentialing processas identified to the Director of OperationsMonitoring.
  • Prepare reports detailing credential verification issues to pertinent field staff and credentialverification agent.
  • The monthly provider credentialing status report for review by the Director of Operations Monitoring.
• Review and comply with the Code of Business Conduct and all applicable company policies and procedures, local, state and federal laws and regulations.
• May escalate issues to supervisor for resolution, as deemed necessary.
• Assist with various projects as assigned by direct supervisor.
• Other duties as assigned.

Additional responsibilities may include focus on one or more departments or locations.  See applicable addendum for department or location specific functions.

Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.