Cooperative Care Credentialing Specialist

JOB SUMMARY:

This position is responsible for all aspects of the credentialing, re-credentialing and privileging processes for all CooperativeCare Providers including medical providers employed by Ephraim McDowell Health. Responsible for ensuring providers are credentialed, re-credentialed, and participating with health plans, hospitals and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications. Must exhibit the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service, and Trust).

Provides customer support for 200+ providers (physicians and allied health) and their office managers in a six county service area; acts as a provider relations representative for CooperativeCare; responsible for facility credentialing on all entities associated with Ephraim McDowell Health, including Ephraim McDowell Health Resource off-site clinics, MedSource, McDowell Home Health and Ephraim McDowell Home Infusion Pharmacy; provide support for Central Kentucky Physicians, Inc., Medical Director, Board of Directors, and CooperativeCare, Inc. Board of Directors.

ESSENTIAL FUNCTIONS INCLUDE BUT ARE NOT LIMITED TO:

• ADMINISTRATIVE SKILLS

1. Compiles and maintains current and accurate data for all providers.
2. Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed, for Governmental and Commercial Insurance Plans.
3. Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
4. Maintains corporate provider contract files.
5. Maintains knowledge of current health plan and agency requirements for credentialing providers for Governmental and Commercial Insurance Plans.
6. Sets up and maintains provider information in online credentialing databases and system.
7. Tracks license and certification expirations for all entities and providers to ensure timely renewals.
8. Ensures practice addresses are current with health plans, agencies and other entities, for Governmental and Commercial Insurance Plans.
9. Manages DEA and professional liability expirations for EMH providers for reporting.
10. Maintains EMH appointment files and information in credentialing database.
11. Audits health plan directories for current and accurate provider information.
12. Reviews hospital and Clinic reimbursements to ensure payments are accurate with the contracted rate.
13. In the event of a payment variance appeal the under paid portion including submission of all supporting documents.
14. Track recovery payments and document all appeal and recovery activity.

• COOPERATIVECARE PHYSICIAN HOSPITAL ORGANIZATION (PHO) 

1. Maintain and oversee the provider network of membership in CooperativeCare Network of 200+ providers, including physicians, allied health, mental health providers, etc., in six county service area.
2. Acts as a liaison/provider relations representative between office managers, billing departments, credentialing specialists for all CooperativeCare membership to assist and resolve issues with third party payers, MCOs, commercial, Medicaid and Medicare products.
3. Manager of “Messenger Model” for CooperativeCare membership which permits providers to select individually the contracts in which they wish to participate.
4. Work directly with provider relations specialists for all contracted payers (approximately 12 commercial plans, five Managed Care Organizations (MCOs), Medicare and Medicaid, in assisting with provider demographics, etc.
5. Maintain and update CooperativeCare website to keep up-to-date as possible.
6. Maintain the provider network information and add and/or term appropriate providers/demographics to all contracted third party payers.
7. Maintain and revise as needed the “CooperativeCare Credentialing and Recredentialing Plan” (policies and procedures) to ensure compliance with accreditation, state and federal regulatory requirements, and to ensure processes for evaluating and selecting licensed independent practitioners to provide care to its members.
8. Serve as a clearinghouse for various duties for and on behalf of CooperativeCare membership such as insurance credentialing to reduce the burden on the individual physician/group within the network.
9. Communicate important network information from contract payers to CooperativeCare membership regarding changes which directly affect their offices.
10. Distribute workshop and/or educational opportunities to CooperativeCare membership as may be offered by payers.