Tracks the date of provider applications that are submitted until the provider's credentials are approved. Confirms that the correct versions of credentialing applications are being used to avoid delays in finalizing the credentialing process. Coordinates communications with department administrators to confirm provider service locations, etc., which is necessary to properly establish the provider in EPIC for billing purposes. Educates newly credentialed providers on third party payer credentialing and re-credentialing documentation and requirements. Handles all Medicare initial enrollment, re-enrollment, and revalidation activities Handles all Medicaid Initial enrollment, re-enrollment, and revalidation activities Medicaid NC Tracks monthly license updates Medicaid NC Tracks monitoring of Provider Messaging Inbox Participates in Medicaid onsite screenings. Creates credentialed provider templates that are forwarded to the managed care companies to add our providers in their system as well as creating other provider credentialing reports upon request. Coordinates credentialing activities with McKesson (McKesson is the billing entity used by the Department of Pathology). Monitors third party payors online provider directory to ensure that our providers are loaded correctly and can be viewed by the general public. Monitors, tracks, and reconciles Pro-card statement of charges. These are charges related to the Medicaid Enrollment fee. Initiates direct communications with providers and clinical staff to explain the credentialing process. Serves in a liaison capacity between outside agencies and ECUP's provider(s) on all matters relevant to participation in MCO's, Medicare, Medicaid, and Tricare. Maintains, monitors, and updates credentialing databases (Shared Drive and Cactus) Creates and distributes a Monthly Physician Count Report to administration. Review monthly disciplinary action reports issued by state licensure bodies, Office of Inspector General, and Medicare and Medicaid Sanctions reports. Creates a Monthly Sanction Report. Quarterly Reports to all Third Party Payors Quarterly Provider Roster to Insurance Companies and Internal Departments Audits: Facilitates the process of scheduling multiple third party payer credentialing audits (BCBS, Tricare, Cigna, Aetna/Coventry, Medcost, CBHA, & ECBH). Serves as a liaison between the MCO and CVO. Gathers information needed from in house, the CVO, and forwards to the plan. Audits: Facilitate Internal Self Audit Monitors credentialed provider types to identify providers that are eligible to be reimbursed by our contracted third party payors. Maintains provider and clinic demographic information. Responsible for understanding accreditation agency credentialing guidelines (e.g., NCQA, TJC, and URAC). Responsible for understanding healthcare provider license accrediting body guidelines (e.g., NC Medical Board and U.S. DEA as well as the NC Dept. of Insurance.) The Credentialing Specialist is directly involved in the orientation of new departmental personnel and faculty regarding the requirements for participation and coverage of services in each of the various MCP's, Medicare, Medicaid, Champus and BCBS costwise. The Credentialing Specialist serves in a liaison capacity between outside agencies and the School's provider(s) on all matters relevant to participation in MCP's, Medicare, Medicaid, Champus, BCBS. For example, if the Personal Care Plan (PCP) requires additional information from each School of Medicine provider regarding board certification and practice history. The Coordinator would coordinate the gathering of this information from the faculty for submission to PCP. Systems & Claims
Participates in the development of managed care policies and procedures as they relate to provider participation in the various plans. The Provider Relations Coordinator must be familiar with the criteria for provider participation and coverage of services by each of the various health plans with which the school contracts. Many of the rules for participation and coverage by Medicare, Medicaid, and Campus are mandated by federal law. These laws and associated paperwork are complicated, voluminous, and can result in significant financial penalties and sanctions if not completely adhered to. The coordinator relies upon government publications such as Federal Register, bulletins, and newsletters to stay abreast of these regulations and assure timely completion of necessary paperwork and practice compliance. An example includes enrollment and coverage of non-physician practitioners. The criteria vary by type of practitioner (i.e. nurse practitioner, physician extender, clinical social worker, etc.) and coverage of practitioners' services is governed by the Health Care Financing Administration (HFCA). HFCA sets forth a set of rules and regulations which are usually more restrictive that State licensing and certification requirements. For enrollment and billing purposes, HCFA regulations must be adhered to. Each Managed Care Plan also differs in participation requirement at the School, Clinic, and individual provider level. The Provider Relations Coordinator must be familiar with the details of each MCP contract. Support is provided and oversight for projects that are assigned to other staff or students (i.e., Scanning of Credentialing Files into X-tender or enrollment applications). Has a complete understanding of the Credentialing Coordinator role and steps in to handle issues when the Credentialing Coordinator is not available. The Provider Relations Coordinator is directly involved in the orientation of new departmental personnel and faculty regarding the requirements for participation and coverage of services in each of the various MCO's, Medicare, Medicaid, and Tricare cost wise. Various projects that arise related to provider credentialing and enrollment. This can be due to changes with a MCO or government plan and an action plan that is needed.
CLINICALSUPPORTPOSITION – NOTSUBJECT TO STATEHUMANRESOURCESACT.
The ECU Brody School of Medicine is affiliated with Vidant Medical Center. Vidant Medical Center is the flagship hospital for Vidant Health and serves as the teaching hospital for the Brody School of Medicine at East Carolina University.
Special Instructions To Application:
Please ensure your full range of knowledge, skills, abilities, experience and education are listed on your application. Do not write ‘see resume’ on your application when completing the job duties section.
If you answer the questions at the end of the application, please ensure your application reflects the knowledge, skills, abilities and experiences to support your answers (see job duties section of previous employment).
Failure to answer the questions at the end of the application will not preclude your application from being considered but may result in your application not receiving full consideration of your knowledge, skills, and abilities.
Bachelor’s degree and one year of experience related to the area of assignment; or equivalent combination of training and experience. All degrees must be received from appropriately accredited institutions.
Full time or Part time: Full Time
Position Location (city): Greenville
Position Number: 951111
Organizational Unit Overview:
Clinical Finance and Business Support Services/Group Practice Administration is responsible for the clinical and administrative oversight of the group practice for ECU Physicians. The practice is comprised of approximately 360 faculty physicians, 52 contracted providers and employs a diverse clinical support staff of more than 1,200 individuals, of which approximately 350 employees are working within revenue cycle operations The practice provide approximately 550,000 outpatient, 155,000 emergency room and 126,000 inpatient services annually to nearly 160,000 patients. Clinical Finance and Business Support Services reports to the ECU Physicians (ECUP) Executive Director and ECUP Chief Financial Officer to support key fiscal and operational components of the clinical practice and revenue cycle operations. These include direct management responsibility for staffing and operations in the centralized functions of the Central Billing Office (CBO) and oversight for decentralized activities. Centralized functions include: Payor Contracting and Evaluation, Regulatory Compliance and Credentialing; Computer System and Procedure Training; Insurance and Patient Billing, Follow-up and Collections; Cash Management of Professional Fee Revenue; Business Intelligence Services such a Reporting and Analytics; Coordinated Patient Access Support; and Contact Center Decentralized functions include: Registration, Referral Management, Pre-Service Financial Preparation; Service Identification and Reconciliation; Coding and Charge Entry; and Project Management and Process Improvement.
To be a national model for student success, public service and regional transformation, East Carolina University uses innovative learning strategies and delivery methods to maximize access; prepares students with the knowledge, skills and values to succeed in a global, multicultural society; develops tomorrow's leaders to serve and inspire positive change; discovers new knowledge and innovations to support a thriving future for eastern North Carolina and beyond; transforms health care, promotes wellness, and reduces health disparities; and improves qualify of life through cultural enrichment, academics, the arts, and athletics. We accomplish our mission through education, research, creative activities, and service while being good stewards of the resources entrusted to us. East Carolina University delivers on the promise of opportunity. We open doors. We improve lives. We transform the present, and we discover the future. In these ways and more, we serve our community, our state, our nation and our world as together we reach toward our greatest potential. Tomorrow starts here.