JOB DESCRIPTION

JOB TITLE:Provider Enrollment/Medical Staff Coordinator

JOB CODE: 2188

GRADE:21

FLSA STATUS:

DEPARTMENT:Medical Affairs & Professional Credentialing

EFFECTIVE/UPDATE DATE:11/2016

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SUMMARY:

Responsible for coordination and preparation of medical staff functions. Assists with all functions related to the credentialing and provider enrollment of practitioners as outlined in the medical staff bylaws, policies or related contracts or as required by accrediting and regulatory agencies (i.e., TJC, CMS, NCQA). Ensurescompliance with appropriate accrediting and regulatory agencies. The Coordinator assists with the development, planning and implementation of the credentialing/privileging and provider enrollmentprocess. Ensures that all expirables are reviewed, obtained, and managed on a monthly basis. Maintains the confidentiality of all business/work and medical staff information. Responsible for the accuracy and integrity of the credentialing and enrollment database systems. Prepares for committee meetings, takes minutes, processes and distributes appropriate correspondence. Assists in managing the flow of information between the OMAPC team, Credentials, MSEC, Board committee members, Medical Staff Leadership (including the Department Chairs and Program Administrators).Other related administrative duties as assigned. Works under the supervision of the Office of Medical Affairs and Professional Credentialing Manager.

SPECIFIC DUTIES:

  • Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents for all credentialingand provider enrollment ofphysicians and allied health applicants.
  • 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 department chair, Credentials Committee, and Medical Executive Committee.
  • Provides administrative management to various committees through document generation/agenda/minutes in preparation for meetings.
  • Coordinates out-of-state Medicaid enrollment process for the PO Foundations.
  • Builds and maintains CAQH files for providers.
  • Submits enrollment paperwork for all major health plans in the State.
  • Enrollsstaff for ordering and referring status with Mass Health and Medicare.
  • Maintains enrollment database with their effective dates with the payers.
  • Works with delegated payers to maintain accurate enrollment rosters.
  • Processes provider terminations with all payers.
  • Manages deadlines as appropriate.
  • Performs miscellaneous job-related duties as assigned.

SUPERVISION EXERCISED: None

MINIMUM JOB QUALIFICATIONS:

  • Bachelor’s degree required. In lieu of degree, will consider individual with 2-4 years directly related experience in provider enrollment and/or credentialing in a health care setting.
  • Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) certification(s)preferred.
  • Requires 3 years experience in medical staff services/provider enrollment credentialing.
  • Knowledge of managed care or provider credentialing required.
  • Knowledge of billing processes preferred.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

  1. Working knowledge of MSOW software preferred.
  2. Working knowledge of Microsoft office software
  3. Ability to organize/prioritize workload with minimal supervision.
  4. Excellent written and verbal communication skills.
  5. Strong customer service orientation and the ability to interact with diverse groups.

PATIENT CONTACT:None

WORKING CONDITIONS:

Standard office environment.

DISCLAIMER: (THIS WILL REMAIN FOR ALL JOB DESCRIPTIONS)

The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job. Requirements are subject to possible modification to reasonably accommodate qualified individuals with disabilities. This document does not create an employment contract, implied or otherwise, other than an “at will” employment relationship.

APPROVALS:

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