Job Summary: To perform all initial credentialing and re-credentialing activities according to PCC Policies as a Mixed Specialty Group, and work as a liaison between our PCC providers, the IPA groups, hospital affiliated groups, and all contracted insurance health plans.
Essential Duties and Responsibilities:
Coordinates PCC credentialing process for medical, dental and behavioral health providers.
Meets with candidates to gather appropriate documentation, ensuring completeness and accuracy.
Coordinates credentialing process with CVO.
This includes follow-up with candidates to ensure all documents are completed in a timely manner.
Double checks CVO verifications.
Coordinates PCC privileging process for medical, dental and behavioral health providers.
Distributes, explains, and collects privileging applications from candidates.
Facilitates and ensures review and approval of privileges by CMO.
Coordinates PCC re-credentialing process for medical, dental and behavioral health providers.
Ensures re-credentialing and privileging occur within proscribed timeline.
Coordinates process with CVO.
Distributes and collects peer evaluations.
Works with Medical Director of Performance Improvement to incorporate quality standards into re-credentialing.
Informs CMO and provider when credentialing/privileging and re-credentialing is complete.
Gathers and submits all necessary documentation to ensure credentialing with Medicaid, Medicare, commercial insurers and managed care plans for medical, dental and behavioral health providers.
Verifies that credentialing is completed.
Informs appropriate PCC staff when credentialing is completed.
Ensures such credentials are updated as needed.
Ensure that billing staff and CMO are aware when a provider’s status with Medicaid, Medicare, and commercial insurers will no longer be active.
Gathers and submits all necessary documentation to ensure credentialing and privileging with hospitals for medical providers.
Informs appropriate PCC staff when credentialing and privileging is completed.
Ensures such credentials and privileges are updated as needed.
Track expiration date of provider licenses and certifications; notify providers of upcoming expiration; and facilitate renewal.
This includes medical licenses, prescription licenses and specialty Board certification.
Ensure that all licensed independent practitioners maintain active licensure.
Maintain knowledge of Joint Commission standards and state and federal regulations with regard to provider credentialing and privileging.
Attend training sessions and conferences as needed to maintain this knowledge.
Maintain records of credentialing and privileging for PCC providers.
Responsible for making sure that all Athena Credentialing Provider Enrollment and Claims worklist task and personal buckets are monitored and completed in a timely fashion.
Associate Degree is required.
Five to seven years of commensurable experience in healthcare is required.
Minimum of two years of Medical provider Credentialing experience in a Healthcare Center or Hospital is preferred.
Two years’ experience handling various types of insurances relating to Medicare, Medicaid, Managed Care, and Commercials is required
Familiar with Joint Commission and NCQA accreditation is required.
Must be able to remain in a stationary position 50% of the time.
Must be able to move around the clinic site 50% of the time.
Constantly operates a computer, computer printer, copy machine, and telephone.
Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
Must be able to transport from one site to another.
Must be able to cover other shifts as necessary.
Ability to read and write proficiently using the English language.
Proficient in MS Office Business Applications to include: Outlook, Word, PowerPoint, and Excel.
Excellent business writing skills.
Ability to function independently, works under pressure, and prioritize multiple projects.
Ability to establish and maintain effective working relationships with supervisors, senior management staff, medical staff, co-workers, community leaders and the general public. Must be able to exchange accurate information in these situations.
Additional Salary Information: Compensatory with experience.
The mission of PCC is to improve health outcomes for the medically underserved community through the provision of high quality, affordable, and accessible primary health care and support services. Anchored with family medicine, we are committed to serving the needs of all people in all stages of life, while we continue to specialize in the delivery of comprehensive maternal and child health servic...es to address this unmet need in our community.
PCC prides itself in providing a model work environment. PCC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws.
For more information on PCC Community Wellness, please visit our Web site at http://www.pccwellness.org